VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vienna Manor III, LLC
10137 Palmer Drive
Oakton, VA 22124
(703) 938-2715

Current Inspector: Alexandra Roberts

Inspection Date: Aug. 5, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 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.

Comments:

An unannounced renewal inspection was conducted on 8/5/19 (8:10 AM - 12:40 PM). At the time of entrance, eight residents were in care. Meals, medications administration, and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of four resident records and three staff records. 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 #:	22VAC40-73-70-A
Description:	Based on record review, the facility failed to report to the regional licensing office, within 24 hours of any major incident that has negatively affected the health, safety, or welfare of any resident. Evidence: The record of Resident #1 contained wound notes, dated 7/23/19 and 7/30/19, that identify the resident as having a stage 3 pressure ulcer. No reports were sent to the licensing office regarding the resident's stage 3 wound.
Plan of Correction:	Resident is currently receiving hospice care. Resident went to the wound doctor the next day after the inspection for wound staging/ clarification. Wound Doctor provided a wound report dated 8/6/19 that resident?s #1 wound is Stage 2 only and smaller in size.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) is based upon the uniform assessment instrument (UAI). Evidence: The UAI for Resident #2, dated 6/1/19, states that the resident needs only supervision for dressing. The ISP for Resident #2, dated 6/1/19, states that the staff will physically help Resident #2 with dressing and undressing. The UAI for Resident #4, dated 4/2/19, states that the resident needs only supervision for dressing. The ISP for Resident #4, dated 4/3/19, states that the staff will dress and undress the resident, and also allow Resident #4 to participate during the process.
Plan of Correction:	Resident #4 and resident #2?s UAI updated for needing Physical assistance. The Administrator and house manager will both review the UAI and ISP to ensure to reflect the needs of the resident.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and interview, the facility failed to ensure that menu substitutions or additions are recorded on the posted menu. Evidence: During the inspection, turkey breakfast casserole was listed as the breakfast dish on the menu. Residents were observed eating waffles. Facility staff reported that waffles were prepared, as the residents wanted them for breakfast. No substitutions were recorded on the posted menu.
Plan of Correction:	The administrator immediately posted the substitution for breakfast as the resident requested to have waffles instead of turkey casserole. The administrator provided an in service to all the staff regarding posting the food substitution on the menu board as requested by the resident.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure that the medication administration record (MAR) includes all of the required information. Evidence: There was conflicting information about the effectiveness of Resident #1's PRN Miralax on 8/3/19 (8 AM). The front of the MAR indicated that the medication was not effective. The back of the MAR listed the medication as being effective. The symptoms, for the administration of Resident #1's PRN Miralax, were not documented on 8/4/19 (8 AM).
Plan of Correction:	The administrator documented the symptom for the administration of Miralax for resident #1.The administrator immediately notified the MT and she corrected the documentation at the back of the MAR as effective. The administrator provided an in service about proper documentation at the MAR.
Standard #:	22VAC40-73-710-B
Description:	Based on observation, the facility failed to ensure that physical restraints are only used (i) as a medical/orthopedic restraint for support, according to a physician's written order and with the written consent of the resident or his legal representative or (ii) in an emergency situation after less intrusive interventions have proven insufficient to prevent imminent threat of death or serious physical injury to the resident or others. Evidence: During the inspection, side rails were observed on the bed of Resident #5. The resident was lying in bed and staff members were not present in the bedroom. The UAI for Resident #5, dated 4/5/19, states that transfers are performed by others and that the resident is disoriented in all spheres, some of the time. Resident #5's ISP, dated 4/5/19, states that the resident needs a hospital bed and half siderails for turn and reposition every 2-3 hours and bed mobility. The ISP lists the resident as non-ambulatory and that the resident is confined to the bed. No physician's orders were found to document the resident's need for side rails and no documentation was found to indicate that the resident is capable of using the side rails as an assistive device.
Plan of Correction:	Administrator obtained a clarification order from the physician to keep the half siderail resident for resident #5. The administrator educated all the staff that the half siderails is only needed when resident is being turned and repositioned every 2-3 hours.