The Virginia Home

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to completely develop a policy for the monthly drug regimen reviews with times frames for the different steps in the process, including identifying an irregularity that requires urgent actions to protect the resident for five residents reviewed for medications, (Residents #18, #38, #43, #83 and #109), in the survey sample of 31 residents. The findings include: The facility, Consultant Pharmacist policy failed to include any documentation regarding the timeframe that a pharmacy recommendation is required to be provided to the physician and acted upon by the physician. The policy did not meet regulatory requirements of specifying those time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. During the unnecessary medication review and drug regimen review, the following resident records were reviewed: Resident #18's clinical record was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and clinical record review, the facility staff failed to ensure one of 31 residents in the survey sample was free from an unnecessary medication; Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant (blood thinning) medication Eliquis (1). A review of R38's clinical record revealed a physician's order dated 11/3/20 for Eliquis five milligrams by mouth two times a day for pulmonary embolism. A review of R38's MARs (medication administration records) for May 2023 through July 2023 revealed the resident was administered Eliquis five milligrams two times each day. Further review of R38's clinical record (including the MARs and nurses' notes for May 2023 through July 2023) failed to reveal the resident was monitored for side effects (bleeding) from Eliquis. On 7/19/23 at 9:03 a.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated residents that are administered anticoagulants should be monitored for bleeding every shift. RN #2 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and review of facility's documentation, it was determined that the facility failed to promote and enhance each resident's right to a dignified and respected existence for three of 31 residents in the survey sample, Resident #60, #50 and #35. The findings included: 1. For Resident #60, the facility staff failed to ensure the resident was treated with dignity and respect. The resident had been sexually abused by a staff member. Resident #60 was admitted to the facility on [DATE]. A review of the facility synopsis of event dated 4/10/23 revealed Incident Type: allegation of abuse/mistreatment. (Resident #60) reported an incident to the nursing supervisor. He stated that while getting his brief changed two days ago, his CNA (certified nursing assistant) mouth touched his penis for two seconds. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/6/23, coded the resident as scoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and clinical record review, the facility staff failed to implement the comprehensive care plan for one of 31 residents in the survey sample, Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to implement the resident's comprehensive care plan for anticoagulant medication monitoring. R38's comprehensive care plan dated 7/31/20 documented, (R38) is on anticoagulant therapy .Monitor for side effects and effectiveness Q (every)-SHIFT . A review of R38's clinical record revealed a physician's order dated 11/3/20 for Eliquis (1) five milligrams by mouth two times a day for pulmonary embolism. A review of R38's MARs (medication administration records) for May 2023 through July 2023 revealed the resident was administered Eliquis five milligrams two times each day. Further review of R38's clinical record (including the MARs and nurses' notes for May 2023 through July 2023) failed to reveal the resident was monitored for side effects (bleeding) from Eliquis. On 7/19/23 at 9:03 a.m., an interview was conducted with RN (registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for two of 31 residents in the survey sample, Residents #6 and #34. The findings include: 1. For Resident #6 (R6), the facility staff failed to review and revise the care plan after the resident returned from the hospital with kidney stones. The hospital Discharge summary dated , 4/24/2023, documented in part, Discharge Diagnoses/Plan: Complicated UTI (urinary tract infection) in the setting of right-sided obstructive ureteral stone with hydronephrosis treated with cystoscopy and stent and IV (intravenous) antibiotics. Completed total of 14 days of antibiotics, discharged on oral ciprofloxacin to cover both Citrobacter and Enterococcus. Patient will need outpatient follow-up with urology for definitive stone management. The hospital Discharge summary dated , 5/19/2023, documented in part, Discharge Diagnosis/Plan: Sepsis due to urinary tract…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to store a resident's nebulizer mask in a sanitary manner for one of 31 residents in the survey sample, Resident #93. The findings include: For Resident # 93 (R93) the facility staff failed to cover the nebulizer mask when it was not in use. R93 was admitted to the facility with diagnoses that included but was not limited to wheezing. Resident #93's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/06/2023, coded Resident #93 as scoring a 15 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions. On 07/17/23 at approximately 3:17 p.m., an observation of R93's room revealed a nebulizer mask on R93's desk uncovered. On 07/18/23 at approximately 8:21 a.m. and 12:35 p.m., observations of R93's room revealed a nebulizer mask on R93's desk uncovered. The physician's order for Resident # 93 documented in part, Albuterol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and facility document review it was determined facility staff failed to store and prepare food in a sanitary manner. The facility staff failed to ensure a table-top and floor mixer that were ready for use, were cleaned and free from food debris. The facility staff failed to maintain a 30 inch fan blowing on clean dishes and cups, located in the clean dish area of the kitchen, clean and free of dust. The facility staff failed to ensure a gallon container of apple cider dressing with an open date of 12/27/2021 was available for use. The findings include: On 02/01/2022 at approximately 11:20 a.m., an observation of the facility's kitchen was conducted with OSM [other staff member] # 1, nutritional service director, with the following concerns: 1. Observation of the table-top mixer located in the facility's kitchen was conducted with OSM # 1. Observation of the table-top mixer revealed the bowl and whisk were cover with plastic wrap. When asked if the mixer was cleaned and ready for use OSM # 1 stated yes. After OSM # 1 removed the plastic from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the required written notification of a hospital transfer to the resident representative RR) upon a transfer to the hospital for four of 32 residents in the survey sample; Residents #45, #44, #31, and #116. The facility staff failed to provide written notification to the Resident #45's resident representative (RR) of hospital transfers on 12/13/19 and 1/1/20. The facility staff failed to provide written notification to the resident representative (RR) of Resident #44's hospital transfer on 1/31/20. The facility staff failed to evidence that written notification of transfer was provided to the resident or resident's representative for a facility-initiated transfer on 12/11/2019 for resident #31 and failed to provide Resident # 116 and Resident # 116's representative written notification of a facility-initiated transfer on 11/27/19 for Resident #116. The findings include: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, it was determined that facility staff failed to ensure the secure storage of controlled medications and failed ensure prefilled syringes were labeled with an expiration date, not expired and not available for use in two of two medication rooms observed, (the third and fifth floor medications rooms). A black metal box, one containing a 30 ml (milliliter) bottle of lorazepam was observed inside the third floor medication room refrigerator and two 30 ml (milliliter) bottles of lorazepam and twenty, 1 ml syringes of lorazepam were observed inside the fifth floor medication room refrigerator. The black metal boxes were not secured and could easily be removed. In the fifth floor medication room [ROOM NUMBER] ml [milliliter] syringes filled with sterile water without an expiration date were available for use. The findings include: On [DATE] at 2:50 p.m., an observation of the facility's medication room on the third floor was conducted with LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to meet mandatory training requirements for eight of 10 CNA (certified nursing assistant) educational records reviewed, (CNA #6, #1, #2, #3, #4, #8 , #9 and #10). The findings include: On 2/19/20, educational records of 10 CNA (Certified Nursing Assistants) were reviewed. The following concerns were identified: - CNA #6, for the anniversary year of 10/30/18 to 10/30/19, did not have all the required 12 hours of annual training. CNA #6, had 9 hours and did not have the required annual training for abuse. - CNA #1, for the anniversary year of 2/16/19 to 2/16/20, did not have the required annual abuse training. - CNA #2, for the anniversary year of 7/7/18 to 7/7/19, did not have all the required 12 hours of annual training. CNA #2, had 6 hours and did not have the required annual training for abuse and dementia care. - CNA #3, for the anniversary year of 5/10/18 to 5/10/19, did not have all the required 12 hours of annual training. CNA #3, had 4.75 hours and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, and facility document review it was determined that facility staff failed to maintain the dignity for one of 32 residents in the survey sample, Residents # 5. The facility staff posted pictures of Resident #5 with positioning instructions and the residents name on the wall above the resident's bed. The postings could be viewed by visitors or staff not involved in the residents care and Resident #5 stated she did not like the postings on the wall. The findings include: Resident # 5 was admitted to the facility with diagnoses that included but were not limited to: cerebral palsy [1] and pressure ulcer of the sacral [tail bone] area. Resident # 5's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 11/14/2019, coded Resident # 5 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident #…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, and facility document review it was determined that facility staff failed to maintain privacy for one of 32 residents in the survey sample, Residents # 5. The facility staff posted positioning instructions with pictures of Resident #5 and the residents name on the residents wall beside the resident's bed. The posted care instructions and pictures of the resident could be easily viewed by visitors or staff not involved in the residents care. The findings include: Resident # 5 was admitted to the facility with diagnoses that included but were not limited to: cerebral palsy [1] and pressure ulcer of the sacral [tail bone] area. Resident # 5's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 11/14/2019, coded Resident # 5 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 5 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.