Oakhurst Health & Rehabilitation
OAKHURST HEALTH & REHABILITATION in FORK UNION, VA — inspection on September 10, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
psychiatry nurse practitioner assessed R201 on 7/30/25 after the incident and determined there was
included police involvement, an attempted emergency custody order and allegations from R201
from the CNA assigned to R201 on the early morning of 7/30/25 (CNA #2) and documented no investigation addressing R201's allegation that assistance was not provided or that his rights had been violated.
The investigation included no interviews with residents about the incident, did not document if any residents witnessed the incident or if any residents heard R201's verbal threats and vulgar language. On 9/9/25 at 9:40 a.m., the maintenance director (other staff #1) that witnessed the 7/30/25 incident was interviewed.
The maintenance director stated on 7/30/25, R201 made verbal threats of physical violence toward him and the nursing staff.
The maintenance director stated R201 directed aggressive comments toward the staff members but that there were several residents in the area when the incident took place. On 9/9/25 at 12:00 p.m., the current administrator and regional nurse consultant (administration #3) were interviewed about reporting/investigating of the 7/30/25 incident of verbal aggression.
The administrator stated he was not working in the facility at the time of the incident and that the former administrator conducted the investigation.
The administrator stated he thought the incident had not been reported to the state agency or APS because the verbal threats were directed toward staff members and not residents.
The administrator stated the investigation included statements from staff about R201's aggressive behaviors and described events surrounding R201's behaviors.
The administrator provided no evidence that the investigation addressed R201's report that assistance was not provided by staff. On 9/9/25 at 3:18 p.m., CNA #2 that cared for R201 at the time of the incident on 7/30/25 was interviewed. CNA #2 stated, prior to today, she had not been interviewed or asked to provide a statement about the events on 7/30/25.The facility's policy titled Abuse (revised 10/20/22) documented, .This facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property .
Designated staff will immediately review and investigate all allegations or observations of abuse.
The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility .to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) .
The facility's policy titled Abuse Investigation and Reporting (10/01/21) documented, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown and thoroughly investigated by facility management. [Sic] Findings of abuse investigations will also be reported .The individual[s] conducting the investigation may, at a minimum .Review the resident's medical record to determine events leading up to the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview the staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, visitors .Review all events leading up to the alleged incident .This finding was reviewed with the administrator and regional nurse consultant on 9/9/25 at 3:50 p.m. with no further information provided prior to the end of the survey.
495230 09/10/2025
Oakhurst Health & Rehabilitation 4238 James Madson Highway Fork Union, VA 23055
(revised 10/20/22) documented, .The organization will maintain systems to ensure that all alleged
the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily
not result in serious bodily injury, to the administrator of the facility .to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) .
This finding was reviewed with the administrator and regional nurse consultant on 9/9/25 at 3:50 p.m. with no further information provided prior to the end of the survey.
495230 09/10/2025
Oakhurst Health & Rehabilitation 4238 James Madson Highway Fork Union, VA 23055
interviewed about the reporting/investigating of the 7/30/25 incident of verbal aggression.
The
statements from staff about R201's aggressive behaviors and described events surrounding R201's
that assistance was not provided by staff. On 9/9/25 at 3:18 p.m., CNA #2 that cared for R201 at the time of the incident on 7/30/25 was interviewed. CNA #2 stated, prior to today, she had not been interviewed or asked to provide a statement about the events on 7/30/25.The facility's policy titled Abuse Investigation and Reporting (10/01/21) documented, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown and [are] thoroughly investigated by facility management .The individual[s] conducting the investigation may, at a minimum .Review the resident's medical record to determine events leading up to the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview the staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, visitors .Review all events leading up to the alleged incident .This finding was reviewed with the administrator and regional nurse consultant on 9/9/25 at 3:50 p.m. with no further information provided prior to the end of the survey.
495230 09/10/2025
Oakhurst Health & Rehabilitation 4238 James Madson Highway Fork Union, VA 23055
requests.R201's plan of care (revised 6/2/25) documented the resident required assistance with
included, Physical assist as needed with ADL care .resident uses disposable briefs.
Change q [every]
.The facility's policy titled Answering the Call Light (undated) documented, The facility will maintain a functional call light system and will make all reasonable efforts to ensure timely responses to the resident's requests and needs .'Timely Response': is not defined by a 'pre-set' measure of minutes but rather is defined that the response time was appropriate to situation and/or need.
Response time varies based on each situation and is impacted from the resident's need and perception/understanding of the urgency and time lapse .If the resident needs assistance, indicate the approximate time it will take for you to respond .If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask an appropriate staff member for assistance .This finding was reviewed with the administrator, DON and regional nurse consultant on 9/10/25 at 11:50 a.m. with no further information presented prior to the end of the survey.
495230 09/10/2025
Oakhurst Health & Rehabilitation 4238 James Madson Highway Fork Union, VA 23055
urinalysis with culture for one of seven residents in the survey sample (Resident #201).The findings
infarction, diabetes, hypertension, peripheral vascular disease, history of myocardial infarction with defibrillator/pacemaker, dysarthria, anxiety, depression, chronic pain syndrome, heart failure, adult failure to thrive, history of prostate cancer, and congestive heart failure.
The minimum data set (MDS) dated [DATE] assessed R201 as cognitively intact. R201's clinical record documented on 7/1/25 that the resident reported burning with urination and discolored urine.
The provider was notified, and a physician's order was entered dated 7/1/25 for a urinalysis with culture and sensitivity. A nursing note dated 7/5/25 documented, urine sample being sent to lab. R201's clinical record documented no results of the urinalysis with culture ordered on 7/1/25.On 9/9/25 at 3:50 p.m., the regional nurse consultant (administration #3) was interviewed about results of the urinalysis ordered on 7/1/25.
The nurse consultant reviewed the clinical record and stated she did not find results of the urinalysis with culture.On 9/10/25 at 10:55 a.m., the regional nurse consultant stated she contacted the lab.
The regional nurse consultant stated the lab picked up samples from the facility on 7/5/25, but there was no record that R201's urine sample was picked up or processed by lab personnel. A lab listing for R201 was presented with no urine sample sent or picked up by the lab in response to the 7/1/25 order.
The regional nurse consultant was not sure why the sample was not provided to the lab.This finding was reviewed with the administrator and regional nurse consultant on 9/10/25 at 11:30 a.m. with no further information presented prior to the end of the survey.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.