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: May 1, 2019

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS

Comments:

Two licensing inspectors completed a one day monitoring inspection at Oakmont at Gordon Park on May 1, 2019. The inspection started at 11:30 am and concluded at 1:20 pm. The focus of this inspection was to address previous violations. During the inspection staff interviews were conducted, a sample of resident records were reviewed, the noon medication pass was observed, medication cart audits were conducted and the building was observed. An exit meeting was held with the administrator on May 1, 2019.and at that time opportunity was given to find items that were not available in files. As a result of this inspection 3 violations are being cited. Please develop a plan of correction for each cited violation with a date of correction and return a signed copy back to the licensing office within 10 calendar days (05/20/2019) of receipt. If you have any questions or concerns please contact your licensing inspector at 276-608-3514. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-310-A
Description:	Based on review of resident records including the physical exam, physicians orders, wound care documentation, and the Individualized Service Plan, the facility retained a resident be retained who requires a level of care or service for which the facility is not licensed. EVIDENCE: 1. Resident # 6 was admitted to the facility on January 31, 2019 from a discharging nursing/rehabilitation home facility. 2. Staff # 1 stated the discharging nursing home did not indicate this resident had any prohibitive condition or any other issues in which the facility could not meet the resident's needs. 3. Staff # 1 stated once the resident was admitted on January 31, 2019 it was discovered through a skin assessment that resident # 6 has two wounds one located on her lower left extremity and one on her left heel. These wounds were not noted and no prohibitive condition was marked on the physical exam for resident # 6 dated January 29, 2019. 4. Staff # 1 stated she was not aware of the wounds prior to resident # 6's admission. 5. Staff # 1 stated she requested documentation on the wounds from the discharging nursing home. The facility obtained Physicians orders on January 30, 2019 that addressed abrasions of the lower left extremity and the left heel and included directions on how to clean and dress the wounds. 6. The facility obtained wound management documentation on January 30, 2019 from the discharging nursing home. The information from the documentation was dated for January 25, 2019 stated resident # 6 had an unstageable wound. 7. Staff # 1 stated once the documentation was received and the wounds were discovered Home Health was contacted right away. 8. Staff # 1 provided the Licensing Inspector with documentation where resident # 6 was referred to Wound Care on March 19, 2019 due to the wounds not healing. The documentation from the wound clinic dated March 19, 2019 states the wound to resident # 6's left heel is a chronic Unstageable Pressure Injury and has a status of not healed and the wound located on the lower left extremity is a chronic Venous Ulcer and has received a status of not healed. 9. Resident # 6 began receiving hospice services on April 25, 2019 due to the wounds continuing not to heal. 10. Documentation received from Hospice dated April 25, 2019 states the wound on resident # 6's left heel is a stage 4 pressure ulcer with a width of 4.5 cm and depth of 3.5 cm with bloody drainage. The wound bed is white/gray nonviable tissue with loose yellow/tan slough. The surrounding tissue is red and inflamed. The wound is being packed with wet to dry and covered with telfa. Documentation from Hospice dated April 30, 2019 states the wound on resident # 6's left heel is a stage 4 pressure ulcer with a width of 4.5 cm and a depth of 3.5 cm with serosanguinous and purulent drainage and is continuing to be packed with wet to dry and covered with aquacel.
Plan of Correction:	The resident was admitted based on physician signed paperwork and family interviews. Both of those, usually reliable, sources failed to note a prohibited condition. Going forward we will do more further investigations and question doctors paperwork to ensure we are maintaining standards at admission. Administrator also met with admissions of the discharging community the Resident came from and discussed the issue and educated them on importance of accurate admission paperwork.
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the noon medication pass, the facility failed to administer all resident medications consistent with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Staff # 2 was observed administering medications during the noon medication pass to three residents. 2. Resident # 7 was in bed in his room. Staff # 2 left the medication cart unlocked in the hallway outside of his room, walked through his sitting room into his bedroom to administer medications. Leaving the unlocked medication cart in the hallway outside of her line of vision.
Plan of Correction:	This nurse was educated on keeping medication cart locked, although this nurse maintains it was locked while she stepped away. Director of Health Service and Administrator are conducting random daily audits of carts to ensure they are locked.
Standard #:	22VAC40-73-870-E
Description:	Based on observations made during the tour of the building, the facility failed to maintain all furnishings in good repair. EVIDENCE: 1. The toilet seat in the common bathroom beside the hair salon was observed to be very loose and wobbly, moving from side to side on the toilet.
Plan of Correction:	The loose toilet seat was fixed the day of inspection. All other toilet seats in the building were audited to ensure there were no other loose seats. Director of Plant Operations will begin randomly checking toilet seats to ensure they are not "loose and wobbly."