The Virginia Home

In the surveyor’s words

From the most serious findings on record at The Virginia Home, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 19, 2023

  Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect three of 31 residents in the survey sample from abuse (Residents #60, #50 and #35), which resulted in harm cited at past non-compliance. The findings include: 1. The facility failed to protect Resident #60 from sexual abuse from CNA (certified nursing assistant) #5. 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. […]

• Actual harm, isolatedF689Jul 19, 2023

  Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to prevent accidents that resulted in fractured bones for two of 31 residents in the survey sample, Residents #43 and #71. This was cited at harm past non-compliance. The findings include: 1. For Resident #43 (R43), the facility staff failed to transfer the resident with a Hoyer mechanical lift, per the resident's plan of care. This resulted in a fall and R43 sustained a fractured clavicle. R43's comprehensive care plan dated 7/31/17 documented, (R43) requires assistance with ADL (activities of daily living) tasks r/t (related to) Dx (diagnoses): Cerebral Palsy, Spasticity and Mood Disorder. Approaches/Tasks: FULL MECHANICAL LIFT-Hoyer Lift for all transfers. […]

• No harm, potential for more than minimal, patternF756Jul 19, 2023

  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. […]

• No harm, potential for more than minimal, patternF757Jul 19, 2023

  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. […]

• No harm, potential for more than minimal, patternF812Feb 3, 2022

  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 [DATE] was available for use. The findings include: On [DATE] 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. […]