Laurels of University Park: Pain Med Order Gap - VA
What he had working against him was a medication order that nobody ever fixed.
The resident, identified in inspection records only as R2, was prescribed two opioid medications simultaneously during his stay in March 2025. One was Oxycodone-Acetaminophen, 5-325 mg, to be given every eight hours as needed when his pain registered between a four and a six. That order had a range. It told nurses something. The other was Oxycodone ER, an extended-release formulation, 10 mg, to be given every 12 hours for moderate to severe pain. That order had nothing. No number. No threshold. No guidance on what "moderate to severe" meant in practice, or at what point a nurse was supposed to act on it.
Extended-release oxycodone is not a mild drug administered for mild discomfort. It is a long-acting narcotic, and the difference between giving it and withholding it is not a small clinical question.
The facility's own policy was unambiguous on what should have happened. When an order is missing a component, a licensed nurse contacts the physician for clarification. The order for Oxycodone ER 10 mg was missing a component. It had been missing that component throughout March 2025. No one contacted the physician.
LPN #3, interviewed by inspectors on the afternoon of October 28, described R2 with the kind of detail that comes from actually knowing a patient. He came in for rehab, had wounds, was alert, knew his wife, had dialysis. When shown the March medication administration record and asked directly whether the Oxycodone ER order should have been clarified to include a pain-level range, LPN #3 did not hesitate. "Yes," the nurse said. "I would have expected the staff to clarify the Oxycodone ER 10 mg give 1 tablet by mouth every 12 hours for moderate to severe pain to include a number range."
Expected the staff to clarify it. Past tense. The nurse knew what the order was missing and knew it should have been fixed, and the conversation with inspectors was apparently the first time anyone had said so out loud.
R2 was also prescribed Lexapro for depression and Renvela to manage phosphorus levels in his blood, a standard concern for dialysis patients whose kidneys can no longer filter that mineral on their own. The inspection record also notes that Narcan, the opioid overdose reversal medication, was part of his care picture. That detail sits in the report without elaboration, but it is not incidental. Narcan is not stocked or noted in a patient's record as a formality. Its presence signals that the people caring for R2 understood, on some level, the weight of the medications they were managing.
The weight of managing them correctly, it turned out, was another matter.
Inspectors rated the violation as having caused minimal harm or potential for actual harm, and noted that only a few residents were affected. The finding was cited under F0658, which concerns professional standards of care.
At 2:45 in the afternoon on October 28, the administrator, the director of nursing, and a regional clinical coordinator were told what inspectors had found. The inspection record notes that no further information was provided before surveyors left the building.
What the record does not contain is any account of what happened to R2 in the months between March 2025 and the October inspection, any indication of whether the incomplete order affected the pain management he actually received, or any explanation of how an order for a scheduled narcotic moved through March without anyone calling the prescribing physician to ask a single clarifying question.
LPN #3 knew what should have happened. The facility's own written policy described what should have happened. The gap between those two facts and what actually occurred during R2's stay is where the violation lives, and it is a gap the inspection record leaves open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Laurels of University Park from 2025-10-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
THE LAURELS OF UNIVERSITY PARK in RICHMOND, VA was cited for violations during a health inspection on October 28, 2025.
What he had working against him was a medication order that nobody ever fixed.
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.