Inspection Reports for
Oakmont at Gordon Park
401 Gordon Ave, BRISTOL, VA, 24201
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
89 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Monitoring
Census: 89
Deficiencies: 7
Date: Mar 26, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations including failure to secure harmful materials in the safe unit, incomplete healthcare oversight documentation, medication management deficiencies, unsecured medication storage, incomplete oxygen therapy orders, building maintenance issues, and incomplete fire and emergency evacuation drawings.
Deficiencies (7)
Facility failed to ensure harmful materials were inaccessible to a resident in the safe, secure unit.
Facility failed to identify specific residents for whom health care oversight was provided.
Facility failed to follow their written plan for medication management including improper medication handling and documentation.
Facility failed to keep medications in a locked storage area during medication pass.
Facility failed to ensure oxygen therapy orders contained all required information including oxygen source.
Facility failed to maintain the interior of all buildings in good repair, including non-operable lights.
Facility failed to include required items on the fire and emergency evacuation drawing.
Report Facts
Residents present: 89
Resident records reviewed: 13
Staff records reviewed: 3
Staff interviews conducted: 5
Residents for health care oversight: 90
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-05 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint related inspection triggered by allegations in resident care and related services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 3
Number of residents present: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Monitoring
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with the criminal history record report standards.
Findings
The inspection found no violations of applicable standards or laws during the visit.
Report Facts
Number of staff records reviewed: 1
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: Nov 18, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-11-08 regarding allegations related to resident care and related services at the assisted living facility.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting allegations of non-compliance with resident care standards.
Findings
The investigation supported the allegations of non-compliance with standards related to resident supervision and staff recordkeeping. Violations were issued for failure to provide adequate supervision of resident schedules and care, and for failure to obtain criminal history record reports for staff within the required timeframe.
Deficiencies (2)
Facility failed to provide supervision of resident schedules, care, and activities, resulting in a resident remaining on the toilet for approximately one hour without assistance.
Facility failed to ensure that the criminal history record report was obtained on or prior to the 30th day of employment for an employee.
Report Facts
Number of residents present: 90
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 4
Duration resident remained on toilet: 60
Inspection Report
Renewal
Census: 99
Deficiencies: 2
Date: Mar 27, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility Oakmont at Gordon Park on March 27 and 28, 2024.
Findings
The inspection found non-compliance with applicable standards related to maintenance and cleanliness of the facility, including stains on carpets, chipped paint, water stains on ceiling tiles, and foul odors in some resident areas. Violations were documented and a plan of correction was submitted.
Deficiencies (2)
Facility failed to ensure the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish, including stains on carpets, chipped paint, and water stains on ceiling tiles.
Facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors, with an odor resembling urine observed in resident room #1208.
Report Facts
Number of residents present: 99
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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Current inspector conducting the inspection |
| Director of Plant Operations | Named in plan of correction related to maintenance and cleaning |
Inspection Report
Monitoring
Census: 91
Deficiencies: 0
Date: May 2, 2023
Visit Reason
The inspection was a monitoring visit conducted to review the physical plant, administration, resident accommodations, and grounds of the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the facility and reviewed resident records without identifying any deficiencies.
Report Facts
Number of resident records reviewed: 4
Number of interviews conducted with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Monitoring
Census: 91
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
The inspection was a monitoring visit conducted to review personnel and resident care related services at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. Staff training records were reviewed and the physical plant was toured without any deficiencies noted.
Inspection Report
Renewal
Census: 91
Deficiencies: 12
Date: Apr 13, 2023
Visit Reason
The inspection was a renewal type conducted on April 13, 2023, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including improper blood glucose monitoring practices, failure to maintain up-to-date violation notices, lack of dietitian oversight for special diets, medication administration inconsistencies, improper use and documentation of physical restraints, unsafe storage of cleaning supplies, and expired items in the first aid kit. Plans of correction were proposed for each violation.
Deficiencies (12)
Failed to implement blood glucose monitoring practices consistent with CDC recommendations; glucometer not labeled with resident's name.
Failed to maintain and display the most recent violation notice at the facility.
Failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist.
Failed to ensure medications are administered according to physician's orders and medication aide standards; discrepancies in medication administration records and pharmacy labels.
Failed to document all medications administered on the medication administration record (MAR), including over-the-counter medications.
Failed to ensure restraints (quarter rails) were used only with a physician's written order specifying conditions, circumstances, and duration.
Failed to meet required conditions when physical restraints were used, including monitoring and assistance documentation.
Failed to document the need for quarter rails on the individualized service plan for the resident.
Failed to store cleaning supplies in a locked area; unsecured cleaning chemicals found in unlocked cabinets.
Failed to store cleaning supplies or hazardous materials so they are not accessible to residents with serious cognitive impairment.
Failed to keep furnishings, fixtures, and equipment clean and in good repair; loose corner handrail in memory care unit.
Failed to remove and replace expired items in the first aid kit; triple antibiotic ointment expired since 04/2018.
Report Facts
Residents present: 91
Resident records reviewed: 9
Staff records reviewed: 5
Resident interviews conducted: 4
Staff interviews conducted: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Current inspector conducting the inspection |
| Staff #6 | Reported on use of quarter rails and resident's knowledge of their use | |
| Staff #7 | Confirmed lack of dietitian oversight and missing MAR documentation | |
| Director of Health Services | Responsible for monitoring compliance and corrective actions related to medication and restraints | |
| Executive Director | Responsible for displaying most recent inspection results and monitoring compliance | |
| Director of Culinary Services | Responsible for monitoring cleaning supplies storage compliance | |
| Director of Plant Operations | Corrected loose handrail and responsible for ongoing compliance monitoring |
Inspection Report
Census: 88
Deficiencies: 1
Date: Feb 17, 2023
Visit Reason
The inspection was conducted as a result of a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of general supervision and care.
Findings
The investigation supported the self-report of non-compliance with standards or law, specifically a failure to provide supervision of one resident's schedule, care, and activities, including attention to specialized needs. Violations were issued based on interviews and evidence.
Deficiencies (1)
Facility failed to provide supervision of one resident's schedule, care, and activities, including attention to specialized needs.
Report Facts
Number of residents present: 88
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews with residents: 1
Number of interviews with staff: 2
Temperature: 66
Inspection Report
Monitoring
Deficiencies: 0
Date: Jun 3, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various regulatory provisions related to assisted living facilities.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal B. Mullins | Licensing Inspector | Inspector who conducted the inspection and signed the inspection summary. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 17, 2022
Visit Reason
A complaint inspection was conducted on May 17, 2022, following a complaint received on March 31, 2022, regarding allegations in the area of resident related care.
Complaint Details
Complaint received by VDSS Division of Licensing on 03/31/2022 regarding allegations in the area(s) of resident related care. Evidence did not support non-compliance.
Findings
The investigation included interviews with residents and staff, and the evidence gathered did not support non-compliance with standards or laws related to resident care and provisions. No violation notice was issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal B. Mullins | Licensing Inspector | Named as the inspector who conducted the inspection and issued the inspection summary. |
| Rebecca Berry | Current Inspector | Listed as the current inspector for the facility. |
Inspection Report
Renewal
Census: 87
Deficiencies: 10
Date: Mar 17, 2022
Visit Reason
Two licensing inspectors conducted an unannounced license renewal inspection at Oakmont at Gordon Park on 03/17/2022 to assess compliance with licensing standards and regulations.
Findings
The inspection identified 10 violations related to medication management, storage, labeling, resident safety, and facility maintenance. Corrective action plans were required to address noncompliance and prevent recurrence.
Deficiencies (10)
Facility failed to have a physician or other prescriber’s order for any medication, dietary supplement, diet, medical procedure, or treatment to be started, changed, or discontinued.
Facility failed to store all medications administered by the facility in a locked area.
Facility failed to ensure that medications are only kept in resident rooms when a resident is assessed as being able to self-administer their own medications.
Facility failed to administer medications consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Facility failed to ensure that over-the-counter medication shall remain in the original container, labeled with the resident’s name.
Facility failed to have all medications ordered for as needed (PRN) administration be available, properly labeled for the resident, and properly stored.
Facility failed to have 'No Smoking-Oxygen in Use' signs posted on every room where oxygen is used.
Facility failed to ensure that all pets prior to living on the premises have had all required immunizations and certified by a licensed veterinarian to be free of disease transmittable to humans.
Facility failed to maintain the water temperature on taps available to residents between 105-120 degrees Fahrenheit.
Facility failed to store cleaning supplies and other hazardous materials in a locked area.
Report Facts
Violations cited: 10
Residents in care: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Named as the current inspector conducting the inspection. |
| Staff #1 | Mentioned in relation to pet immunization and hazardous materials findings. |
Inspection Report
Monitoring
Census: 81
Deficiencies: 0
Date: Mar 29, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards and laws.
Findings
The inspection reviewed resident and staff records, schedules, oversight reviews, and recent fire and health inspection reports, concluding with no violations or deficiencies found.
Report Facts
Resident census: 81
Resident records reviewed: 5
Staff records reviewed: 5
Staff schedule review period: 14
Oversight review period: 365
Fire and health inspection reports reviewed: 1
Fire and emergency drills review period: 365
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 25, 2020
Visit Reason
A complaint inspection was initiated due to a complaint received by the department regarding allegations in the areas of infection control.
Complaint Details
Complaint related to infection control; investigation concluded with no substantiation of non-compliance.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
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