VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Alexandra Roberts

Inspection Date: May 3, 2023

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 22VAC40-80 THE LICENSING PROCESS

Technical Assistance:

Documentation was discussed with the provider.

Comments:

An unannounced renewal inspection was conducted on 5/3/23. At the time of entrance, seven residents were in care. Building and grounds were inspected and activities were observed. Medications and records were reviewed. The sample size consisted of four resident records and three staff records. The violation was discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-70-C
Description:	Based on record review, the facility failed to ensure that a written report of each serious incident is reported to the regional licensing office, within seven days of the date of the incident. Evidence: Resident #1's record was reviewed during the inspection. A progress note, dated 2/28/23, stated that Resident #1 was found on the floor and she was taken to the hospital. Resident #1 sustained an injury and did not return to the facility until 3/24/23. No incident report was submitted to the regional licensing office, within seven days of the incident.
Plan of Correction:	As our plan of correction, Vienna Manor Administrator will notify licensing at all times within 7 days of when resident incident report is completed and resident has sustained an injury. Resident involved is back to the community and doing well. Correction applied: Vienna Manor management will notify licensing as noted above moving forward.