VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Oakmont at Gordon Park
401 Gordon Ave
Bristol, VA 24201
(276) 644-4800

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Feb. 17, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 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:

Standard #:	22VAC40-73-460-D
Description:	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: 1. 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. 2. Staff #1 confirmed the abovementioned information via in-person interview with the LI at the facility on 02/17/2023. 3. 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. 4. 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]