VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Marian Manor
5345 Marian Lane
Virginia beach, VA 23462
(757) 456-5018

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: June 4, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Technical Assistance:

Admission, Retention And Discharge Of Residents Buildings And Ground

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 06/04/2024 at 08:00 am until 03:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: Breakfast, lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as evidenced by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence: 1. The record for resident # 1, contains a risk assessment for TB dated 4/26/23. The resident?s record did not contain an annual risk assessment for TB completed after 4/26/23. 2. Staff # 1 confirmed the record for resident #1 did not contain an annual risk assessment for TB completed after 04/26/23. 3. The record for resident # 2, contains a risk assessment for TB dated 4/21/23. The resident?s record did not contain an annual risk assessment for TB completed after 4/21/23. 4. Staff # 1 confirmed the record for resident #2 did not contain an annual risk assessment for TB completed after 04/26/23.
Plan of Correction:	1) The risk assessment for TB was completed for residents #1 and #2, on 6/4/24. 2) An audit was completed by the Lynnhaven Cove Coordinator and QA Nurse to ensure each resident has an annual TB assessment completed. 3) Tickler process introduced to assure residents who were LOA/hospital/rehab are screened upon return. 4) Annual risk assessments are completed in May of each year and the QA nurse will audit upon completion that the assessment has been done. 5) The Director of Nursing or designee will review the audit and submit to the QA committee, for their review. Completed: 6/17/2024
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. Resident?s #3 ISP dated 05/22/24 was not signed and dated by the resident, or the legal guardian. 2. Resident?s # 4 ISP dated 06/02/24 was not signed and dated by the resident, or the legal guardian.
Plan of Correction:	1) The Individualized Service Plans (ISP?s) for residents #3 and #4 have been signed and dated, by the resident. 2) An audit will be performed, by the Coordinators to ensure each resident?s ISP has the appropriate signatures and dates for any updates that have been performed. 3) The Coordinators will perform audits to ensure updates have appropriate signatures and dates prior to being placed on the medical record. 4) The Director of Nursing, or designee, will review the audits and submit to the QA committee, for their review. Completed: 6/30/2024
Standard #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #5 contains a physician order dated 05/03/24 that includes ?Digoxin 125mcg tablet, take 1 tablet by mouth daily for A-Fib, Hold if apical pulse is (less than) <60.? Resident?s #5 medication administration record (MAR) documents the resident was not administered Digoxin on the following dates when the resident?s Pulse was documented as being greater than 60: 05/05/24 and 05/11/24. 2. The record for resident #1 contains a physician order dated 05/14/24 that includes ?Calmoseptine, apply in intergluteal buttocks daily and as needed daily for redness excoriation.? Resident?s #1 MAR does not include documentation the resident was applied Calmoseptine daily on the following dates: 05/16/24 through 05/22/24; 05/25/24 through 05/30/24; 05/31.
Plan of Correction:	1) The medication administration time for resident #1s Calmoseptine was clarified and corrected by the Coordinator, on 6/4/2024. 2) The perimeters for resident #5s Digoxin was reviewed by the Medication Aides and nursing staff and additional medication aide training will be provided at the Medication Aide refresher training on 6/20/2024. 3) Each coordinator will perform an audit to review the Physician Orders against the Medication Administration Records (MAR) to assess for accuracy in the orders and on the MAR. 4) The 11-7 nurse, will check physician orders, against the MAR for completion and accuracy, nightly. The Coordinators will perform an audit of Physician orders against the MAR to ensure compliance with accuracy is achieved. Audits will occur weekly x4, then monthly x3. 5) The Director of Nursing, or designee, will review the audits and submit to the QA committee, for their review.
Standard #:	22VAC40-90-50-B
Description:	Based on the record review the facility did not ensure a new sworn statement or affirmation was obtained within 30 days of hire. Evidence: 1. The record for staff #7 contains a sworn disclosure dated 3/10/23; the staff?s hire date is 10/27/23. 2. Staff #8 verified that the sworn disclosure in the record was the most current document.
Plan of Correction:	1.) The sworn disclosure was completed by staff #7 and dated on the day of completion 6-4-24. 2.) Sworn disclosures will be audited as completed by the Administrative Assistant for the correct date. 3.) The Business manager will audit the date on sworn disclosures prior to filing the personnel file. 4.) All staff completed a sworn disclosure in the month of June as a part of the annual update.