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: March 17, 2022

Complaint Related: No

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 ?-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:

Standard #:	22VAC40-73-650-A
Description:	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]
Standard #:	22VAC40-73-660-A
Description:	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: 1. 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]
Standard #:	22VAC40-73-660-B
Description:	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]
Standard #:	22VAC40-73-680-D
Description:	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: 1. 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. 2. 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:	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]
Standard #:	22VAC40-73-680-G
Description:	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: 1. 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]
Standard #:	22VAC40-73-680-M
Description:	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: 1. 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. 2. 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. 3. 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]
Standard #:	22VAC40-73-700-2
Description:	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: 1. 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]
Standard #:	22VAC40-73-840-A
Description:	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: 1. 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. 2. 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]
Standard #:	22VAC40-73-860-G
Description:	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: 1. 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]
Standard #:	22VAC40-73-860-I
Description:	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]