Oakmont at Gordon Park — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Oakmont at Gordon Park was inspected 16 times between November 25, 2020 and April 8, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 9 with none. Across that history VDSS cited 38 violations under 33 distinct standards. 5 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 13 of these 16 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

05/04/2027

Administrator

Hillary Akers

Licensing inspector

Rebecca Berry

Inspector phone

(276) 608-3514

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

April 8, 2026Complaint survey0 violations

Inspection dates

04/08/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/08/2026, 1:25pm to 2:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/30/2026 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 31, 2026Inspection4 violations

Inspection dates

03/31/2026

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/31/2026, 9:41am to 3:51pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Noon meal, activities, medication pass Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

22VAC40-73-930-D

Based on resident record review, the facility failed to include all required documentation on the two-hour rounding charts for residents who have the inability to use the signaling device.

Evidence

The two-hour rounding chart completed on 03/22/2026 did not include the staff member’s documentation at 3pm and 5pm for residents #9 and #8 and on 03/30/2026 at 3pm and 5pm for resident #8.

Plan of correction

Direct care staff are receiving ongoing education between 3/31/26 and 4/30/26 on documentation procedures. Director of Health Servies/Designee is auditing rounding documentation weekly for 8 weeks to ensure compliance. [SIC]

22VAC40-73-1090-A

Based on resident record review, the facility failed to have all required components included on the assessment for one resident prior to being placed in a safe, secure environment.

Evidence

Resident #9 was admitted to the safe, secure unit of the facility on 09/05/2025.
The “Assessment of Serious Cognitive Impairment” was completed on 09/05/2025. The second page of the “Assessment of Serious Cognitive Impairment” which addresses: behavior/psychomotor; speech/language; and appearance was not available at the time of inspection.

Plan of correction

Resident #9’s Assessment of Cognitive Impairment was corrected. Director of Community Relations and Administrative Assistant will be reeducated by 4/30/26 on admission requirements. [SIC]

22VAC40-73-680-K

Based on the review of Medication Administration Records (MARs), physician’s orders, staff interview, and resident files, the facility failed to have all requirements in place for the use of as needed (PRN) medications.

Evidence

Resident #8 was admitted to the facility on 06/03/2024.
The most recent Uniform Assessment Instrument (UAI) for resident #8 was completed on 02/16/2026. The UAI states resident #8 needs assistance with medication administration and a nurse including RMAs will provide the assistance. The UAI also states the resident is approved for assisted living in the memory care unit and she is disoriented to some spheres (place and time) all the time.
The Individualized Service Plan (ISP) completed on 2/16/2026 for resident #8 states she is receiving medication administration by nursing staff including RMAs and medications will be administered per physician’s orders. The ISP also documents the need for reorientation to spheres of place and time, placement in the memory care, and has an inability to independently use the call bell and direct care staff will perform two-hour rounds, at minimum, to monitor for emergencies or other unanticipated needs.
The March 2026 MAR and the 03/03/2026 corresponding physician’s orders for resident #8 has the following medications listed for PRN use, but did not include details including symptoms that indicate the use of the medication, and/or directions as to what to do if symptoms persist: a. Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) MCG/ACT, one puff inhale orally every four hours as needed for wheezing related to shortness of breath. b. Ativan Oral Tablet 1mg, give one by mouth every six hours as needed for signs and symptoms of fidgety, yelling out, unable to re-direct related to restlessness and agitation. c. Guaifenesin Oral tablet 400mg, give one tablet by mouth every 12 hours as needed for congestion. d. Ondansetron Oral Tablet, disintegrating 4mg, give one tablet by mouth every eight hours as needed for nausea, nausea/vomiting. e. Senna Oral Tablet 8.6mg, give one tablet by mouth every 24 hours as needed for constipation. f. Tylenol Oral Tablet 325mg, give two tablets by mouth every six hours as needed for pain related to pain. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)

Plan of correction

Signs and symptoms were added to the order for Resident #8 and Resident #9 on 4/17/26. All charts will be audited by 4/30/26 for signs and symptoms if the Resident is not capable of requesting the medication themselves. All nursing staff will be educated by 4/30/26 on the requirement of signs and symptoms for PRN orders for Residents not capable of requesting the medication themselves. New PRN orders will be audited weekly for the next 6 weeks to ensure proper signs and symptoms are listed by the Director of Health Services/Designee. [SIC]

22VAC40-73-870-E

Based on observations made during the tour of the building, the facility failed to keep furnishings, fixtures, and equipment clean and in good repair.

Evidence

The common bathroom (Room #058) had an inoperable light above the handwashing sink/mirror.
The cabinet under the fish tank in the dining area had discolored areas which appeared white. The same cabinet door on the left side was discolored with black/brown spots and splashes of an unknown substance.
The common bathroom (Room #058) had a paper towel dispenser that was inoperable and paper towels were not available. There was not a hand dryer available in this bathroom.

Plan of correction

The lightbulb above the mirror was replaced on 3/31/26. The Director of Plant Operations will do an audit of the building by 4/30/26 to ensure all other lightbulbs are working. By 4/30/26 he will do a training with his staff on reporting maintenance issues. The cabinet under the fish tank was cleaned. The fishtank is located in the dining room and the discolored areas came from a spilled plate. Kitchen staff will be educated by 4/30/26 to wipe down the fish tank with their dining room cleaning. [SIC]

March 26, 2025Inspection7 violations

Inspection dates

03/26/2025

Areas reviewed

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/26/2025, 9:25am to 3:55pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 89 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 13 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

22VAC40-73-640-A

Based on observations during the tour of the building and the medication cart audit, the facility failed to follow their written plan for medication management.

Evidence

The medication management plan (page 8, #37) states any creams or ointments which are applied with assistance shall be squeezed onto a tongue depressor or similar tool and shall be discarded after application. In the room for resident #10, the LI observed a souffle cup containing Triamcinolone Acetonide External Cream 0.1%, apply to face topically every eight hours as needed for redness/dry/itching skin, left sitting on the bedside table unused and unsupervised.
The medication management plan (page 5, #30) states when assistance is provided with solid doses of oral medication the employee must wash hands. Staff #2 was not observed to wash or sanitize her hands prior to administering 11:00am medication to resident #9.
The medication management plan (page1, #4) states the night nurse/MA will audit medication nightly and order when amount of seven tablets remain to ensure that each resident’s prescription medications are filled and refilled in a timely manner to avoid missed dosages. The March 2025 Medication Administration Record (MAR) for resident #8 indicates Levothyroxine Sodium Oral Tablet, 75mcg is to be administered one time daily. From 03/15/2025 to 03/17/2025 and on 03/26/2025, staff #8 recorded an 11 on the MAR; an 11 indicates the medication was not available in the facility.
The medication management plan (page 3, #18) states the nurse who opens insulin is responsible for labeling and writing the expiration date and initials on the container. The top drawer of the medication cart in the safe, secure unit was observed to have Lantus for resident #11, Lantus and Humalog for resident #12, and FIASP for resident #13; these medications had no open date, no expiration date, and no initials of the nurse that opened the insulin.
The medication management plan (page 3, #19) states: If a medication is unavailable, notify the pharmacy. If unable to obtain in time for the next dose then the nurse should notify the MD and obtain an order to hold the medication until available. This should be documented as a new order. The March 2025 MAR and the order summary report signed 03/18/2025 indicate resident #7 is prescribed the following medication: Florometholone Ophthalmic Suspension 0.1%, Instill 1 drop in both eyes two times a day for inflammation. During the 9am medication pass on 03/26/2025, this medication was not available per staff #1 and was documented on the MAR as unavailable. The medication was documented on the MAR as unavailable at 9am on 03/25/2025. Per staff #28, the medication was ordered following the 9am medication pass on 03/26/2025. There was no order to hold the medication until available in the record for resident #7.

Plan of correction

Staff #2 was educated on handwashing and leaving medications at bedside on 3/26/25. All staff will be inserviced by 4/21/25 on the medication management plan. Medication for Resident #8 was checked to ensure it was present. Insulins were checked and corrected on 3/26/25. Medication for Resident #7 was checked to ensure it was present. Director of Nursing will randomly audit handwashing and unavailable medications weekly for four weeks. Assistant Director of Nursing will randomly audit medications left at bedside and insulin labeling weekly for four weeks. [SIC]

22VAC40-73-960-B

Based on observations made during the tour of the building, the facility failed to include required items on the fire and emergency evacuation drawing.

Evidence

The fire and emergency evacuation drawing located in the assisted living portion of the building did not include areas of refuge, telephones, and fire alarm boxes as appropriate.

Plan of correction

The fire and emergency evacuation drawing located in the assisted living portion of the building will be updated to include areas of refuge, telephones, and fire alarm boxes by 4/18/25. [SIC]

22VAC40-73-490-D

Based on a review of facility documentation, the facility failed to ensure that when the health care oversight is provided, the specific residents for whom the oversight was provided must be identified.

Evidence

A document provided to the LI at the time of inspection indicated the most recent health care oversight occurred on 01/07/2025 with a total number of 90 residents for whom oversight was provided.
Specific residents for whom the oversight was provided were not identified.

Plan of correction

A new healthcare oversight will be done by 4/25/25 using the state form. Executive Director will check oversight for list of Residents attached. Executive Director will check each oversight in the future for attached list. [SIC]

22VAC40-73-660-A-1

Based on observations made during the 11:00am medication pass on 03/26/2025, the facility failed to keep the medications in a locked storage area.

Evidence

During the 11:00am medication pass, staff #2 walked approximately 15 feet away from the medication cart to administer a medication to resident #8 and the LI observed her to leave the medication cart unattended and unlocked in the safe, secure unit.

Plan of correction

Staff #2 was reeducated on securing the med cart on 3/26/25. All other staff licensed to administer medications will be inserviced by 4/21.25. [SIC]

22VAC40-73-1180-B

Based on observations made during the tour of the safe, secure unit, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.

Evidence

Resident #9 resides in the safe, secure unit of the facility.
On the date of the inspection (3/26/25), the LI found the following items in the bathroom for resident #9:
Cerave Itch Relieve Moisturizing Lotion, 8 fluid ounces
Biotin Thickening Hair Treatment, 12 fluid ounces
Shampoo with Emu Oil, 8 fluid ounces
PeriFresh Perineal Cleanser, 7.5 fluid ounces
Deodorant Spray by Dr. Scholl’s 4.7 ounces
Arm and Hammer Shoe Refresher and Odor spray, 4.0 ounces
Arm and Hammer Foot Powder Spray, 7.0 ounces.

Plan of correction

Items were removed from Resident #9’s bathroom on 3/26/25. A reminder of prohibited items will be sent to responsible parties with residents in the secure unit with their bills on 4/15/25. Assistant Director of Nursing will audit the secured unit weekly for four weeks. [SIC]

22VAC40-73-700-1

Based on a review of resident records, the facility failed to ensure that when oxygen therapy is provided, the physician's or other prescriber's order contains all required information, including the oxygen source, such as compressed gas or concentrators.

Evidence

The record for resident #3 contains two orders for oxygen: Oxygen 2L NC PRN mild-moderate dyspnea and Oxygen 4L NC PRN severe dyspnea.
The orders do not contain the oxygen source, such as compressed gas or concentrators.

Plan of correction

Hospice provider who wrote the order was reeducated on 4/9/25 to order requirements. All oxygen orders will be audited for clarification on 4/10/25. Director of Nursing will audit weekly for four weeks. [SIC]

22VAC40-73-870-A

Based on observations made during the tour of the building, the facility failed to ensure that the interior of all buildings shall be maintained in good repair.

Evidence

The wall sconce light across from rooms #1222, #1242, #0065, #0019 and #1224 were not operable.
The overhead light in front of rooms #1214 and #1225 were not operable.

Plan of correction

Director of Plant Operations met with local light company on replacement parts on 4/4/25. Light replacement parts were ordered on 4/9/25. Delivery date is unknown but we expect to have lights replaced by 4/28/25. Director of Plant Operations will audit lights weekly for four weeks for continued compliance. [SIC]

February 26, 2025Complaint survey0 violations

Inspection dates

02/26/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2025, 1:15pm to 2:44pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/05/2025 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 95 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 22, 2025Inspection0 violations

Inspection dates

01/22/2025

Areas reviewed

22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/22/2025, 11:25am to 11:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: n/a Number of staff records reviewed: 1 Number of interviews conducted with residents: n/a Number of interviews conducted with staff: n/a Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 18, 2024Complaint survey2 violations

Inspection dates

11/18/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/2024, 10:16am to 11:19am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/08/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

22VAC40-90-40-B

Based on a review of staff and facility records and interview with staff, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.

Evidence

Based on an invoice from the Virginia Department of State Police dated 04/01/2022, the criminal history record report for staff #1 was requested by the facility on 03/04/2022.
At the time of inspection on 11/18/2024, the criminal history record report for staff #1 was not located in the record for staff #1.
Staff #4 confirmed during the inspection on 11/18/2024 that the criminal history record report for staff #1 could not be located in the record for staff #1, or elsewhere in the facility.

Plan of correction

An invoice was provided during the inspection proving a background check was obtained. Upon contacting the Virginia State Police, we found we could no longer obtain a copy of the paid for check. A new check was ordered on the day of inspection and subsequent results provided to surveyor. An audit of all employee records is being done by the Business Office Manager to ensure records are present. This audit will be completed by 1/24/25 with results given to Executive Director. [SIC]

22VAC40-73-460-D

Based on a review of resident records, staff documentation and interviews with staff, the facility failed to provide supervision of resident schedules, care, and activities.

Evidence

The Uniform Assessment Instrument for resident #1, completed 06/01/2024, indicates resident #1 requires mechanical and human help/physical assistance with toileting.
The individualized service plan for resident #1, completed 06/01/2024, provides the following description of needs and services to be provided regarding toileting: Resident #1 needs mechanical and physical assistance with toileting and staff will assist resident #1 with toileting while using grab bars and allowing resident #1 to participate to resident #1’s maximum abilities.
Per the call system log and interview with staff #1, resident #1 used the call system to request assistance on 11/07/2024 at 10:19pm. Staff #1 reports she cleared the call and notified resident #1 she would return to help after assisting other residents. Per staff #1, resident #1 agreed to wait for staff #1 to return.
Staff #1 reports she assisted resident #1 to the toilet at approximately 11:30pm on 11/07/2024.
Staff #2 and staff #3 report that while looking for staff #1 after midnight on 11/08/2024, they entered the room for resident #1 and found resident #1 on the toilet at approximately 12:25am.
Staff #3 reports resident #1 was assisted from the toilet to her bed by staff after finding her on the toilet at approximately 12:25am on 11/08/2024.
Based on the times provided by staff, resident #1 remained on the toilet for approximately one hour before being assisted back to her bed.

Plan of correction

Resident #1 did not ring her call bell requesting assistance off the toilet during this episode, despite having a pendant around her neck and on the bathroom wall. Resident #1 frequently utilizes her call bell but reeducation will be done with her on activating it when she has a care need by 1/22/25. [SIC]

March 27, 2024Inspection2 violations

Inspection dates

03/27/2024, 03/28/2024

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/27/2024 10:05am to 3:26pm and 03/28/2024 12:15pm to 4:10pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 99 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

22VAC40-73-870-A

Based on observations made during the tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.

Evidence

In resident room #1211, the licensing inspector (LI) observed a large dark stain on the carpeting near the stainless-steel trash can, and several smaller stains on the carpeting near the red recliner.
The entry door to resident room #1234 had dark lines on the lower portion, left side, and areas of chipped paint on the lower portion of the door frame. There was a dark stain on the carpet in the main living area.
The door to laundry room #0021 had a dark line across the width of the door, approx. six inches below the doorknob, and chipped paint in two small areas on the lower left portion of the door frame.
In the hallway near exit door #1 there was a dark line above the baseboard approximately 24 inches in length, and the baseboard below the dark line was discolored in places. At the corner where the baseboards meet, there were dark marks on the baseboards and three small areas of chipped paint on the wall just above the baseboards.
In resident room #1223 there were several small stains on the carpeting in front of the red recliner.
In resident room #1226, dark lines were observed on the lower portion of the closet door and the adjacent baseboard, are areas of chipped paint on the right lower portion of the door frame as you exit the room to the hallway.
In resident room #1002, dark lines were observed across the lower portion of the entry door.
Water stains were observed on ceiling tiles by the activity area/library.
The entry door to resident room #1005 had a dark line approximately 6 inches long on the bottom right portion, and two small areas of chipped paint along the bottom portion of the door fame.

Plan of correction

1. Stains on carpet in #1211 are being cleaned. 2. #1234 door was repainted and stain cleaned. 3. #0021 door was repainted 4. Baseboard in hallway near exit door #1 was repaired/repainted. 5. #1223 carpet was cleaned. 6. #1226 door was painted. 7. #1002 door was painted. 8. Ceiling tiles were replaced. 9. #1005 door was painted. Director of Plant Operations will do an audit of doors and repaint any with issue by 04/30/2024. He will continue this audit monthly for 6 months. Director of Plant Operations keeps an ongoing list of apartments who need commercial carpet cleaning. Housekeeping employees will be retrained on reporting carpets that require commercial attention by 4/12/24. [SIC]

22VAC40-73-870-B

Based on observations made during the tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors.

Evidence

The licensing inspector observed an odor resembling urine upon entering the main living area of resident room #1208 on both 03/27/2024 and 03/28/2024.

Plan of correction

Apartment #1208 was deep cleaned. Director of Plant Operations will monitor cleanliness of apartment #1208 living area weekly for 4 weeks. [SIC]

May 2, 2023Inspection0 violations

Inspection dates

05/02/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/02/2023, 11:10am to 11:47am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 13, 2023Inspection12 violations

Inspection dates

04/13/2023

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/13/2023, 9:10am to 3:57pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Medication pass and noon meal Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

22VAC40-73-860-J

Based on observations made during the tour of the building, the facility failed to store cleaning supplies or other hazardous materials so they are not accessible to residents with serious cognitive impairment.

Evidence

A bottle of shampoo/body wash with the warning “External Use Only” was found in the room for resident #10 in the memory care unit, sitting on the shower rail.

Plan of correction

Shampoo was removed from bathroom on 4/13/23. Director of Health Services/Designee will randomly audit memory care apartments for hazardous material weekly for 4 weeks to ensure continued compliance. [SIC]

22VAC40-73-40-B

Based on observations made during the tour of the building, the facility failed to ensure the facility keeps and maintains information as required by this chapter for assisted living facilities.

Evidence

When the LI asked the front desk concierge where the most recent violation notice could be located, she showed the LI the violation notice displayed which was from 03/20/2021. The 03/20/2021 violation notice was not the most up to date notice issued by the department.

Plan of correction

Executive Director displayed most recent inspection results on 4/13/23. Executive Director/Designee will monitor this weekly for 4 weeks to ensure compliance. [SIC]

22VAC40-73-680-H

Based on a review of medication administration records (MARs) and interviews with staff, the facility failed to document on the MAR all medications administered to residents, including over-the-counter medications and dietary supplements, for one of the resident records reviewed.

Evidence

There were no staff initials on the MAR dated 04/01/2023 to 04/30/2023 indicating the following medications had been administered to resident #12 on 04/04/2023 at 6:00am: Aspirin Capsule 81 MG, Cozaar Tablet 25 MG, Cranberry Tablet 450 MG, Lactobacillus Tablet, Lasix Oral Tablet 20 MG, Meloxicam Tablet 7.5 MG, Synthroid Tablet 25 MG, Vitamin B Complex Tablet (B Complex Vitamins), Zoloft Tablet 100 MG, Seroquel Tablet 25 MG, and Buspirone HCl Tablet 7.5 MG.
Staff #7 was unable to locate documentation explaining the reason for the missing initials on the MAR for resident #12.

Plan of correction

Upon review, Resident did receive medication that day, the nurse failed to accurately sign off the MAR. All nurses will be educated on accurately signing off on the MAR by 5/1/23. Director of Health Services/Designee will monitor MARs weekly for 4 weeks to ensure there are no blanks. [SIC]

22VAC40-73-710-C

Based on observations during a tour of the facility and interview with staff, the facility failed to ensure restraints are used in accordance with a physician’s written order that specifies the condition, circumstances, and duration under which the restraint is to be used.

Evidence

Quarter rails were observed to be on both sides of the bed in the room for resident #15.
Staff #6 reported the rails are used by the resident when staff assist with dressing, changing, and turning.
Resident # 15 lives in the safe secure unit and has a documented serious cognitive impairment.
Staff # 6 reported that resident # 15 doesn’t know what the quarter rails are for or how to use them unless or until instructed by staff.
A physician’s written order for the rails was not found in the record for resident #15. Staff #7 confirmed there is no physician’s written order for the rails for resident #15.

Plan of correction

Restraints were never used on Resident #15 or any other Resident within community. An order was obtained and given to surveyors during their visit showing the quarter rails were used for this Resident for ambulation and it was found to be unsatisfactory. Upon conversation with surveyors it was determined that despite quarter rails being beneficial to the Resident’s care and maximizing the Resident’s ability to participate in their care, it is best for the quarter rails to be removed to meet the requirements of the regulations. Quarter rails were removed on 4/13/23. Director of Health Services/Designee will monitor weekly for 4 weeks to ensure quarter rails formerly used for ambulation are not present. [SIC]

22VAC40-73-100-C-2

Based on observations made during the medication cart audit, the facility failed to implement blood glucose monitoring practices that are consistent with CDC recommendations.

Evidence

The glucometer for resident #11 was not labeled with the resident’s name. The resident’s name was only on the bag in which the glucometer is stored.

Plan of correction

Nurse on duty labeled glucometer for Resident #11 on 4/13/23. All nurses will be educated on labeling glucometers by 5/1/23. Director of Health Services/Designee will monitor this weekly for 4 weeks to ensure compliance. [SIC]

22VAC40-73-870-A

Based on observations made during the tour of the building, the facility failed to ensure all furnishings, fixtures and equipment, including furniture, window coverings, sinks, toilets, bathtubs and showers, shall be kept clean and in good repair and condition.

Evidence

The corner handrail in the hall near room #1429 in the memory care unit is coming apart and is loose.

Plan of correction

Director of Plant Operations corrected loose handrail. Director of Plant Operations will audit weekly for 4 weeks to ensure continued compliance. [SIC]

22VAC40-73-620-A

Based on observations made during facility records review and interview with staff, the facility failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.

Evidence

There were no records available at the facility documenting oversight of special diets by a dietitian or nutritionist within the past six months.
Staff #7 confirmed the most recent oversight by a dietitian or nutritionist occurred on April 19, 2022.

Plan of correction

As relayed to surveyor during survey, attempts were made to make timely dietician visits but due to scheduling the soonest available was 4/24/23. Executive Director has requested dietician to return in September 2023 to ensure next visit in early rather than late. [SIC]

22VAC40-73-980-A

Based on observations of the first aid kit, the facility failed to remove and replace items with expiration dates that have already passed.

Evidence

The one ounce tube of triple antibiotic ointment in the facility’s first aid kit had an expiration date of 04/2018.

Plan of correction

The unopened bottle of antibiotic ointment in the locked first aid kit was removed on 4/13/23. Director of Health Services/Designee will audit all first aid kits for expired materials and lock by 4/28/23. [SIC]

22VAC40-73-710-E

Based on observations during a tour of the facility and interview with staff, the facility failed to ensure required conditions were met when physical restraints were used.

Evidence

The need for the quarter rails was not documented on the individualized service plan for resident #15.

Plan of correction

Restraints were never used on Resident #15 or any other Resident within community. An order was obtained and given to surveyors during their visit showing the quarter rails were used for this Resident for ambulation in addition to an individualized service plan stating the same and it was found to be unsatisfactory. Upon conversation with surveyors it was determined that despite quarter rails being beneficial to the Resident’s care and maximizing the Resident’s ability to participate in their care, it is best for the quarter rails to be removed to meet the requirements of the regulations. Quarter rails were removed on 4/13/23. Director of Health Services/Designee will monitor weekly for 4 weeks to ensure quarter rails formerly used for ambulation are not present. [SIC]

22VAC40-73-860-I

Based on observations made during a tour of the building, the facility failed to ensure cleaning supplies were stored in a locked area.

Evidence

Unsecured bleach, Windex, and furniture polish were found in an unlocked cabinet in an unlocked storage room beside the salon.
Clorox Cleanup spray, Lysol Disinfectant spray and an unknown blue substance/liquid in a spray bottle were found in an unlocked cabinet in the resident dining room.

Plan of correction

Cleaning solutions in both locations were removed 4/13/23. Director of Culinary Services/Designee will monitor cabinets weekly for 4 weeks to ensure continued compliance. [SIC]

22VAC40-73-680-D

Based on observations during review of resident records and medication cart audit, the facility failed to ensure medications are administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

The Medication Administration Record (MAR) dated 04/01/2023 to 04/30/2023 for resident #12 lists Pepto-Bismol Suspension (Bismuth Subsalicylate), give 15 ml by mouth every 8 hours as needed for diarrhea. The instructions on the pharmacy label state take 30ml by mouth every 8 hours as needed for diarrhea. The instructions on the physician’s order dated 09/11/2022 state 1 tsp Q 8 hrs PRN, Dx – diarrhea.
The MAR dated 04/01/2023 to 04/30/2023 for resident #13 lists Acetaminophen Tablet 325 MG, give 2 tablets by mouth every 4 hours as needed for pain. The instructions on the pharmacy label state take 2 tablets by mouth every six hours as needed for pain. The instructions on the physician’s order signed on 09/28/2022 state 2 tablets, oral, as needed for pain, every 4 hours.
The physician’s order information sheet for resident #14 signed 03/10/2023 lists Dronabinol 5 Mg Capsule, take 1 capsule by mouth 2 times a day for supplement, start date 07/06/2021. This medication is not listed on the MAR dated 04/01/2023 to 04/30/2023 for resident #14 and there was no discontinue order found in the record for resident #14.
The MAR dated 04/01/2023 to 04/30/2023 for resident #14 lists both Pyridostigmine Bromide Oral Tablet 60 MG, give 0.5 tablet by mouth every 8 hours related myasthenia gravis with (acute) exacerbation and Pyridostigmine Bromide Oral Tablet 60 MG, give 1 tablet by mouth every 8 hours related myasthenia gravis with (acute) exacerbation. The physician’s order information sheet signed 03/10/2023 for resident #14 lists Pyridostigmine Br 60 Mg tablet, take ½ tablet by mouth three times a day for myasthenia gravis, at 6 a.m., 2 p.m. and 10 p.m. The instructions on the pharmacy label state take ½ tablet by mouth three times a day for myasthenia gravis. From 04/01/2023 to 04/13/2023, staff initialed the MAR in error, beside the instructions for 1 tablet by mouth every 8 hours. Staff #6 obtained a clarification on 04/13/2023 to discontinue the order for Pyridostigmine Bromide oral tab 60 mg give 1 tab PO every 8 hours and to continue Pyridostigmine Bromide oral tab 60 mg give ½ (0.5) tab PO every 8 hours, Dx: myasthenia gravis.

Plan of correction

1. Resident had been receiving correct dose, pharmacy label was incorrect and was corrected 4/13/23. All nurses will be educated on verifying MAR to Pharmacy label by 5/1/23. 2. Resident had been receiving correct dose, pharmacy label was incorrect and was corrected 4/13/23. All nurses will be educated on verifying MAR to Pharmacy label by 5/1/23. 3. Resident has not been and should not have been receiving Dronabinol since 8/6/21. All medications were administered correctly. Updated med list was obtained from physician 4/25/23. 4. Resident has been receiving correct medication dosage and all nurses will be inserviced on putting orders in correctly by 5/1/23. Director of Health Services/Designee will randomly audit 3 charts a week for 4 weeks to ensure pharmacy labels match MAR. Director of Health Services/Designee will randomly audit 10 new orders a week for 4 weeks to ensure they are entered correctly. [SIC]

22VAC40-73-710-D

Based on observations during a tour of the facility and interview with staff, the facility failed to ensure required conditions were met when physical restraints were used.

Evidence

Resident #15 lives on the safe secure unit and has a documented serious cognitive impairment, thus not having the ability to recognize danger. Resident #15 has quarter rails on both sides of her bed and staff #6 reported that resident #15 doesn’t know what the rails are for or how to use them until or unless instructed to use them by staff.
There was no documentation available verifying the condition of resident #15 was closely monitored while using the quarter rails, including checking on the resident every 30 minutes.
There was no documentation available verifying resident #15 was assisted no less than 10 minutes every hour while using the quarter rails, for hydration, safety, comfort, range of motion, exercise, elimination and other needs.
There was no documentation related to usage of the quarter rails, outcomes, checks, assistance required while using the quarter rails and notation of any unusual occurrences or problems.

Plan of correction

April 13, 2023Inspection0 violations

Inspection dates

04/13/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/13/2023, 12:26pm to 12:38pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: Staff training records reviewed An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 17, 2023Inspection1 violation

Inspection dates

02/17/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/17/2023, 12:30pm – 1:10pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 02/15/2023 regarding allegations in the area of: General supervision and care. Number of residents present at the facility at the beginning of the inspection: 88 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations

22VAC40-73-460-D

Based on facility self-report and interviews with staff and one resident, the facility failed to provide supervision of one resident’s schedule, care and activities, including attention to specialized needs.

Evidence

Staff #1 submitted a written report to the LI on 02/15/2023 stating resident #1 was transported by staff #3 to a medical appointment on 02/15/2023. Upon arriving back to the facility, staff #3 parked the vehicle in the parking lot and did not assist resident #1 from the vehicle or help her into the facility. Approximately 45 minutes later, a nurse was attempting to locate resident #1 to administer medication and it was discovered resident #1 was still in the vehicle.
Staff #1 confirmed the abovementioned information via in-person interview with the LI at the facility on 02/17/2023.
Resident #1 confirmed the incident described above via in-person interview with the LI at the facility on 02/17/2023. Resident #1 reports she was left in the vehicle for over an hour.
The Uniform Assessment Instrument dated 06/01/2022 for resident #1 indicates resident #1 requires mechanical and human help, physical assistance in the areas of walking, wheeling and mobility. Staff #1 reports resident #1 primarily uses a wheelchair and was transported to the medical appointment noted above via wheelchair van/bus. The Individualized Service Plan (ISP) dated 06/01/2022 for resident #1 indicates staff will assist resident #1 with wheeling while using a wheelchair. The ISP also indicates staff will help resident #1 be mobile while using a wheelchair. Per interviews with staff #1 and resident #1, staff #3 assisted resident #1 out of the facility via wheelchair and into the wheelchair van prior to the medical appointment referenced above. The resident remained in the wheelchair which was secured in the wheelchair van by staff #3. Staff #3 failed to assist resident #1 out of the vehicle and back into the facility upon their return. Per staff #1, staff #3 and resident #1 left the facility at approximately 9:00am and returned to the facility at approximately 11:30am. According to www.accuweather.com, the high temperature on 02/15/2023 was 66 degrees Fahrenheit.

Plan of correction

Immediately following the incident, Resident #1 was examined by their Nurse and deemed to be unharmed. Staff #3 was immediately sent home and no longer is employed by facility. Staff #1 immediately reported the incident to the Responsible Party for Resident #1 and also reported it to designated Virginia Department of Social Services representative. [SIC] All staff responsible for transporting Residents were retrained on a transportation checklist. Staff will be retrained on checklist monthly for 6 months and then at new hire and annually. [SIC] Manager responsible for staff who transport Residents is doing a random weekly ride along for a month and then monthly for 5 additional months. [SIC]

June 3, 2022Inspection0 violations

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

Type of inspection: Monitoring Date: 05/17/2022 Time: 1:50pm-2:30pm The Acknowledgement of Inspection form was signed and left at the facility on 05/17/2022. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins), Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov Violation Notice Issued: Choose an item. A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Crystal B. Mullins Date Inspection Summary Issued: 6/3/2022

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 17, 2022Complaint survey0 violations

Inspection dates

05/17/2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONS¿22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿22VAC40-73 PERSONNEL¿22VAC40-73 STAFFING AND SUPERVISION¿22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿22VAC40-73 BUILDINGS AND GROUND¿22VAC40-73 EMERGENCY PREPAREDNESS¿22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ARTICLE 1 – SUBJECTIVITY¿32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿63.2 GENERAL PROVISIONS¿63.2 PROTECTION OF ADULTS AND REPORTING¿63.2 LICENSURE AND REGISTRATION PROCEDURES¿63.2 FACILITIES AND PROGRAMS¿22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿22VAC40-80 THE LICENSE¿22VAC40-80 THE LICENSING PROCESS¿22VAC40-80 COMPLAINT INVESTIGATION¿22VAC40-80 SANCTIONS

Comments

Type of inspection: Complaint On 05/17/2022 beginning at 2:30 pm and concluding at 2:50 pm a complaint inspection was completed by the licensing inspector which was on-site at the facility for the date of the inspection. The Acknowledgement of Inspection form was signed and left at the facility on 05/17/2022. A complaint was received by VDSS Division of Licensing on 03/31/2022 regarding allegations in the area(s) of resident related care There were interviews conducted with two different residents at the facility. There were interviews conducted with five different staff members at the facility. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the resident related care and resident related provisions aspect of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Crystal B. Mullins Date Inspection Summary Issued: 6/3/2022

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 17, 2022Inspection10 violations

Inspection dates

03/17/2022

Areas reviewed

Technical assistance

1. Personal hygiene items such as shampoo, conditioner, liquid soap and nail polish was found unsecured in resident rooms on the secure unit. These items could potentially become dangerous if ingested to the residents in memory care due to their serious cognitive impairment. 2. The mechanical room which is located beside the chapel was found unlocked. The wiring could present danger to a cognitively impaired or confused resident inside or outside of the secure unit. 3. The LI found the Medical storage room unlocked and unsecured. There were no medications nor dangerous substances found in this area, please make sure this area is locked and secured if medications were to be stored in this area. 4. Resident #18’s door facing and door was scared and has gouged are approximately ½-1/3 inches long due to an electric wheelchair. 5. One resident had a physician’s order and the same medication was listed on the MAR as Lantaprost Solution 0.005%, instill one drop in both eyes at bedtime. The package with the medication says to administer into both eyes two times daily. The medication aide placed a “change of direction“, sticker on the package while LI was present. Please make sure these changes of direction are promptly attached to the corresponding medications.

Comments

Two licensing inspectors conducted an unannounced license renewal inspection at Oakmont at Gordon Park on 03/17/2022. The inspection began at 9:45 am and concluded at 4:22 pm. A tour of the building and grounds was conducted. Residents and collaterals were interviewed. Resident and staff interactions were observed. The noon meal and the noon medication pass were observed. Resident and staff files were reviewed. Medications and MARs were observed. The facility had 87 residents in care on the date of the inspection. An exit meeting was held with the administrator and other key staff on 03/17/2022 and at that time the opportunity was given to find items that were not readily available in the records. As a result of this inspection, 10 violations are being cited. A corrective action plan should be developed addressing steps to correct the noncompliance of each standard; measures to prevent the reoccurrence; and the person(s) responsible for implementing each step and/or monitoring and prevention measures. The "description of action to be taken" for each violation along with the "date to be corrected" must be retuned to his office signed and dated within 10 days (04/07/2022) of receipt. If you have any questions or concerns please contact your licensing inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations

22VAC40-73-660-B

Based on observations made during the noon medication pass and review of resident records, the facility failed to ensure that medications are only kept in resident rooms when a resident is assessed as being able to self-administer their own medications. EVIDNCE: 1. Resident # 20 had menthol and zinc oxide ointment on his bedside table in his room on the secured unit. This resident did not have a physician’s order to keep this medication at bedside and he is rated as dependent in medication administration. 2. Resident #21 had Cetaphil Lotion on a shelf in his bathroom in the secured unit. This resident did not have a physician’s order to keep this medication at bedside and he is rated dependent in medication administration. 3. Resident #22 had ear wax removal drops and Carmex Medicated lip balm in a caddy which was observed to be beside of the bathroom sink in her room on the secure unit. The resident did not have a physician’s order to keep this medication at bedside and she is rated dependent in medication administration.

Plan of correction

Items in Resident #20, #21, and #22 apartments were removed 3/18/22. Upon clarification from Surveyor all families with loved ones residing on the secured unit will be educated on what items are not permitted. Director of Health Services/Designee will randomly audit 2 apartments a week for 4 weeks to ensure compliance. [sic]

22VAC40-73-680-M

Based on observations made during the noon medication pass and the medication cart audits, the facility failed to have all medications ordered for as needed (PRN) administration be available, properly labeled for the resident, and properly stored.

Evidence

Resident #18 has a physician’s order Albuterol Sulfate Nebulizer Solution 2.5mg/3mL, 0.083%, one inhalation via nebulizer every six hours as needed. This medication for this resident was also listed on Resident #18’s medication administration record (MAR). This medication was not available in the facility for the resident.
Resident #14 has a physician’s order for Hydrocortisone cream 1%, apply to face every 12 hours as needed. This medication for this resident was also listed on Resident #14’s MAR. This medication was not available in the facility for the resident.
Resident #13 has a physician’s order for Glucagon Emergency Kit, inject one mg intramuscularly (IM) every 24 hours as needed for low blood sugar. This medication for this resident was also listed on Resident #13’s MAR. This medication was not available in the facility for the resident.

Plan of correction

PRN Medications for Residents #18, #14, and #13 have been reordered or discontinued due to nonuse. All nurses will be reeducated by 4/14/22 on reordering PRN medications. Director of Health Services/Designee will randomly audit 2 Resident charts for PRN availability each week for 4 weeks to ensure compliance. [sic]

22VAC40-73-660-A

Based on observations made during the tour of the building, the facility to store all medications administered by the facility in a locked area.

Evidence

On the secure unit there was an unlocked workstation cabinet which contained the following medications: Derma Klenz, Antifungal Powder, Betadine, Menthol and Zinc Oxide Ointment, A&D ointment and Nystatin Powder. The staff in memory care stated the home health nurse that visits the facility uses the medications and keeps them stored there.

Plan of correction

Items were removed from secure unit during inspection. Home Health Nurse was educated on location of storing medical supplies day of inspection. Director of Health Services/Designee will randomly audit unsecured workstations in the secured unit 5x weekly for two weeks to ensure compliance. [sic]

22VAC40-73-860-G

Based on observations made during the tour of the building, the facility failed to maintain the water temperature on taps available to residents between 105-120 degrees Fahrenheit.

Evidence

The hand washing sink in the common bathroom beside of the chapel was observed to have a hot water temperature of 129.2 degrees Fahrenheit.

Plan of correction

Director of Plant Operations adjusted water heater and corrected problem during inspection. Director of Plant Operations/Designee will randomly audit 3 water points each week for 4 weeks to ensure compliance. [sic]

22VAC40-73-860-I

Based on observations made during the tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDNECE: 1. The nursing space located on AL3 had a built in wall cabinet. LI found an 85 count Clorox wipes with a warning to “keep out of the reach of children” in the bottom left. Staff #1 stated they served a mixed population in this facility inside as well as outside of the secure unit. 2. Resident #19 was observed to have nail polish remover on a shelf in her bathroom on the secure unit.

Plan of correction

Clorox wipes were removed from wall cabinet and nail polish remover was removed from Resident #19’s apartment the day of inspection. All families with loved ones on the secured unit will be educated via email on appropriate items to bring to community. Director of Health Services/Designee will randomly audit wall cabinet and 2 apartments a week for 4 weeks to ensure compliance. [sic]

22VAC40-73-650-A

Based on observations made during the tour of the building, the facility failed to have a physician or other prescriber’s order for any medication, dietary supplement, diet, medical procedure, or treatment to be started, changed, or discontinued. 1. Resident #15’s room contained a bag in a black cabinet inside of the resident’s room that contained the following medications: Beano, Dulcolax, Systane eye drops, MegaRed, Colon Health and Centrum Silver multivitamin.

Plan of correction

Physician orders were obtained for Resident #15 on over the counter medications to keep at bedside. Education was provided to Resident’s Family who provided referenced medications. Education was sent out via email to all Resident families on 4/7/22 re-educating them to not bring over the counter medications to their loved ones. Signed acknowledgement forms are still being used upon admission of this expectation. Director of Health Services/Designee will randomly audit 2 apartments a week for 4 weeks to ensure compliance. [sic]

22VAC40-73-680-G

Based on observations made during the noon medication pass and the medication cart audits, the facility failed to ensure that over-the counter medication shall remain in the original container, labeled with the resident’s name.

Evidence

On the secure unit, the medication cart contained two bottles of Hemp extract, Smooth Lax, and Skintegrity with no name on the container.

Plan of correction

All unlabeled medications were removed from secured unit med cart day of inspection. All nurses will be reeducated by 4/14/22 on labeling medications. Director of Health Services/Designee will randomly audit 2 medication carts each week for 4 weeks to ensure compliance. [sic]

22VAC40-73-840-A

Based on observations made during the tour of the facility, the facility failed to ensure that all pets prior to living on the premises have had all required immunizations and certified by a licensed veterinarian to be free of disease transmittable to humans.

Evidence

When the LI arrived at the facility there were two mounds of cat food on the concrete entry way to the building and there was also a small animal house observed.
Staff #1 stated the residents like to feed the cats that wonder around from the neighborhood and the raccoons eat from the supply as well.

Plan of correction

Staff #1 was unaware that neighborhood cats that come on property needed to be vaccinated. After learning of this during inspection, Director of Life Enrichment had many failed attempts of trying to catch the cat as the cat is not here daily. Cat was successfully caught on 4/4/22 and brought to local veterinary clinic for vaccination. Staff #1 works day time hours and has never seen raccoons on property. Cat in question has also never been inside the building. If future neighborhood cats come on our property we will attempt to ensure they are vaccinated. [sic]

22VAC40-73-700-2

Based on observations made during the tour of the building, the facility failed to have “No Smoking-Oxygen in Use” signs posted on every room where oxygen is used.

Evidence

Resident #7 had an oxygen concentrator in her room on the secure unit of the building. There was not a no-smoking sign posted in her room or on her door.

Plan of correction

Resident #7 had a sign added to her apartment day of inspection. All other Residents on oxygen were audited for signs on 4/1/22. Director of Health Services/Designee will randomly audit 2 Resident apartment’s for oxygen signs for 4 weeks to ensure compliance. [sic]

22VAC40-73-680-D

Based on observations made during the noon medication pass and the medication cart audits, the facility failed to administer medications consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

Resident #13 is prescribed Latanoprost eye drops, these eye drops were located on the medication cart on the assisted living side of the building. There was no open date found on the container.
Resident #19 is prescribed Alphagan eye drops and Lantaoprost eye drops, both of these eye drops were located medication cart on the secured unit medication cart.

Plan of correction

March 29, 2021Inspection0 violations

Areas reviewed

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 03/29/2021 and concluded on 03/30/2021. The Business Office Manager was contacted by telephone to initiate the inspection. The Business Office Manager reported that the current census was 81. The inspector emailed the Business Office Manager a list of items required to complete the inspection. The inspector reviewed 5 resident records, 5 staff records, the staff schedule for the past two weeks, health care and dietitian oversight reviews for the past year, the most recent fire and health inspection reports, and fire and emergency drills for the past year which was submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 25, 2020Complaint survey0 violations

Inspection dates

Nov. 25, 2020

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 11/25/2020 and concluded on 12/29/2020. A complaint was received by the department regarding allegations in the areas of infection control. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.