VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vienna Manor II, LLC
1914 Horseshoe Drive
Vienna, VA 22182
(703) 403-7583

Current Inspector: Alexandra Roberts

Inspection Date: Jan. 13, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused-monitoring inspection was conducted on 1/13/20 (7:35 AM - 9:10 AM), to follow-up on a high-risk violation that was cited on 10/15/19. Medication administration and resident records were observed. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-B
Description:	Based on observation and interview, the facility failed to ensure that medications remain in the pharmacy issued container until administered to the resident. Evidence: Upon the licensing inspector's entry into the facility's medication room, two pill cups were observed. One cup contained crushed medications and the other cup contained pills. Facility staff reported that the crushed medications were for Resident #1 and the other pill cup was for Resident #2. Resident #2's medications were removed from their pharmacy issued containers, before Resident #1's medications were administered.
Plan of Correction:	The administrator immediately corrected staff about keeping the medications in the pharmacy issued container until administered to the resident. The administrator will conduct medication pass observation to ensure medications remain in the pharmacy issued container until administered to the resident.
Standard #:	22VAC40-73-710-B
Description:	Based on observation and interview, the facility failed to ensure that the requirements for physical restraints were followed. Evidence: Medication administration was observed for Resident #1 and #2, during the inspection. Half rails were observed to be upright on the beds of Resident #1 and #2. Facility staff reported that rails are only to be upright when the residents hold them, while staff are performing care and transferring. Facility staff were not performing resident care or transfers, when the rails were observed on the beds of Resident #1 and #2.
Plan of Correction:	The caregivers forgot to pull down the half siderails after providing care to resident number 1 and 2 on 1/24/2020. The administrator met with all the staff immediately and reviewed the needs for siderail for resident number 1 and 2. The administrator discontinued the half siderails and replace them with bed cane.