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: April 13, 2023

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 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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:

Standard #:	22VAC40-73-100-C-2
Description:	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: 1. 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]
Standard #:	22VAC40-73-40-B
Description:	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: 1. 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]
Standard #:	22VAC40-73-620-A
Description:	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: 1. There were no records available at the facility documenting oversight of special diets by a dietitian or nutritionist within the past six months. 2. 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]
Standard #:	22VAC40-73-680-D
Description:	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: 1. 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. 2. 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. 3. 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. 4. 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 ? 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 ? 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 ? (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]
Standard #:	22VAC40-73-680-H
Description:	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: 1. 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. 2. 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]
Standard #:	22VAC40-73-710-C
Description:	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: 1. Quarter rails were observed to be on both sides of the bed in the room for resident #15. 2. Staff #6 reported the rails are used by the resident when staff assist with dressing, changing, and turning. 3. Resident # 15 lives in the safe secure unit and has a documented serious cognitive impairment. 4. 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. 5. 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]
Standard #:	22VAC40-73-710-D
Description:	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: 1. 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. 2. 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. 3. 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. 4. 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:	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]
Standard #:	22VAC40-73-710-E
Description:	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: 1.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]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during a tour of the building, the facility failed to ensure cleaning supplies were stored in a locked area. EVIDENCE: 1. Unsecured bleach, Windex, and furniture polish were found in an unlocked cabinet in an unlocked storage room beside the salon. 2. 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]
Standard #:	22VAC40-73-860-J
Description:	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: 1. 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]
Standard #:	22VAC40-73-870-A
Description:	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: 1. 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]
Standard #:	22VAC40-73-980-A
Description:	Based on observations of the first aid kit, the facility failed to remove and replace items with expiration dates that have already passed. EVIDENCE: 1. 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]