Oakhurst Health & Rehab: Abuse Investigation Failures - VA
She found that out when an inspector finally interviewed her.
CNA #2, as inspectors identified her, told investigators on September 9 that she had not been contacted, had not been interviewed, and had not provided a statement in the 41 days since the incident. The facility's own investigation, conducted by a former administrator who was no longer in the building by the time inspectors arrived, had gathered statements about the resident's aggressive behavior. It had not gathered anything from the person who was actually there caring for him.
The resident at the center of the incident, identified in inspection records only as R201, had made allegations that morning that went beyond the threats directed at staff. He alleged that assistance had not been provided to him. He alleged his rights had been violated. Those claims, according to inspectors, were documented nowhere in the investigation. The facility's review addressed what R201 did. It did not address what R201 said was done to him.
The maintenance director at Oakhurst was present during the July 30 incident and witnessed it firsthand. He told inspectors on September 9 that R201 had made verbal threats of physical violence toward him and toward nursing staff, and that the threats and aggressive language were directed at staff members. He also told inspectors something the investigation had apparently never captured in writing: there were several residents in the area when all of this was happening.
The facility's investigation included no interviews with any of those residents. It did not document whether any of them witnessed the incident. It did not document whether any of them heard R201's threats or the vulgar language that accompanied them.
A psychiatry nurse practitioner assessed R201 on July 30, after the incident, and recorded that the level of harm was minimal with no credible threat to himself or others. That clinical note appears to be the basis on which the facility made a consequential decision: not to report the incident to the Virginia state survey agency, and not to report it to adult protective services.
The current administrator, interviewed by inspectors on September 9, explained the reasoning plainly. He said he believed the incident had not been reported to the state or to APS because the verbal threats were directed at staff members rather than residents. He was not working at the facility at the time of the incident. The former administrator conducted the investigation. The current administrator said so, and offered nothing further.
What the administrator did not provide, according to inspectors, was any evidence that the investigation had ever examined R201's claim that staff failed to assist him that morning. The investigation addressed R201's behavior. It did not address R201's complaint.
That gap matters because the incident was not a minor behavioral note buried in a chart. It involved police responding to the facility. It involved an attempted emergency custody order. It involved a resident in enough distress, and staff in enough alarm, that the situation escalated to that level before 41 days passed without the assigned aide being asked a single question.
Oakhurst's own written policy, revised in October 2022, commits the facility to investigating all allegations or observations of abuse and to reporting findings to the state survey agency within five working days of an incident. A separate policy from 2021 spells out what an investigation is supposed to include: review of medical records, interviews with witnesses, interviews with the resident, interviews with staff members on all shifts who had contact with the resident during the period in question, interviews with the roommate and family members, and a review of all events leading up to the alleged incident.
The investigation conducted after the July 30 incident met none of those standards for the allegation R201 made about himself. CNA #2, the person most directly positioned to speak to whether assistance was provided, was not interviewed. Residents who were present were not interviewed. The state agency received no report. Adult protective services received no report.
The regional nurse consultant was present alongside the administrator during the September 9 interview in which inspectors walked through these failures. The administrator and the consultant were also present at 3:50 that afternoon when inspectors formally reviewed their findings with facility leadership. The inspection report notes that no further information was provided before the survey ended.
There is a particular quality to what inspectors found at Oakhurst that goes beyond paperwork failures. R201 made an allegation on the morning of July 30. He said he had not received help when he needed it. He said his rights had been violated. The incident that followed, whatever its origins, was severe enough to bring police to the building and to prompt staff to seek an emergency custody order. And then the facility's response was to examine his behavior and leave his complaint unaddressed, to gather statements about what he did and gather nothing about what he said was done to him.
CNA #2 learned for the first time on September 9, from an inspector conducting a complaint survey, that anyone wanted to know what she had seen that morning.
She had been waiting, apparently, for someone to ask.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakhurst Health & Rehabilitation from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
OAKHURST HEALTH & REHABILITATION in FORK UNION, VA was cited for abuse-related violations during a health inspection on September 10, 2025.
She found that out when an inspector finally interviewed her.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.