Oakhurst Health & Rehabilitation

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 facility's policy titled Abuse (revised 10/20/22) documented, .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) .

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Oakhurst Health & Rehabilitation

4238 James Madson Highway Fork Union, VA 23055

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Oakhurst Health & Rehabilitation

4238 James Madson Highway Fork Union, VA 23055

SUMMARY STATEMENT OF DEFICIENCIES

work as a team to provide timely assistance for residents.

The DON stated that CNAs could ask for help from other aides and that nurses were also able to provide care if needed.

The regional nurse consultant stated assistance could have been provided for the early appointment resident so that CNA #2 could help R201 more timely.

The administrator stated again that staff members needed to work together to meet resident needs and requests.R201's plan of care (revised 6/2/25) documented the resident required assistance with activities of daily living (ADL) due to chronic health conditions, muscle weakness, bladder incontinence and used a urinal at times.

Interventions to provide incontinence care and maintain ADLs included, Physical assist as needed with ADL care .resident uses disposable briefs.

Change q [every] 2 hr [hours] and prn [as needed] .Provide supervision and cuing [cueing] as needed with ADL care .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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Oakhurst Health & Rehabilitation

4238 James Madson Highway Fork Union, VA 23055

SUMMARY STATEMENT OF DEFICIENCIES

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to obtain a physician ordered urinalysis with culture for one of seven residents in the survey sample (Resident #201).The findings include:Resident #201 (R201) was admitted to the facility with diagnoses that included cerebral 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.

Facility ID: