VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Alexandra Roberts

Inspection Date: June 11, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Remove or treat the plants in sunroom as they are producing gnats during day/time of inspection.

Comments:

Comments: Type of Inspection: Monitoring Inspection Date of Inspection: June 11 2024 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and participating in other scheduled activities. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-550-F
Description:	Based on observation and record review, facility failed to post the name and telephone number of the appropriate regional licensing supervisor of the department, the Adult Protective Services' toll-free telephone number, the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any substate (i.e., local) ombudsman program serving the area, and the toll-free telephone number of the disability Law Center of Virginia. Evidence: 1. Resident 2?s chart was reviewed, the filed resident?s rights with POA signature did not include required names or telephone numbers. 2. Staff 2 provided copy of resident rights posted in facility and the posted copy did not contain current names and/or telephone numbers. 3. Staff 2 stated that she is new and did not know the names should have been updated.
Plan of Correction:	As our plan of correction, Vienna Manor Administrator immediately updated the name and phone number of the appropriate regional licensing supervisor. This update was made the day of the survey.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation and staff interview, the facility failed to ensure that medications are locked. Evidence: 1. LI entered at 10am to begin inspection. Staff 2 took LI to dining room going past medication cart. Medication cart was in kitchen/dining room unlocked. 2. 10:17am inspection tour completed, and medication cart still unlocked upon return. 3. Staff 2 was by LI informed two times that the medication cart needed to be locked. 4. Residents were in dining room sitting area watching TV. Medications were not being passed at the time.
Plan of Correction:	As our plan of correction, Vienna Manor Administrator immediately reviewed this rule and procedure with staff to ensure this does not happen in the future. This update was made the day of the survey.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interview, the facility failed to ensure a complete first aid kit is on hand without expired items and all items. Evidence: 1. First aid kit on hand did not include: plastic bags, flashlight, or batteries. 2. First aid kit had the following expired items: antibiotic (Exp. 02/25/2023), antibiotic wipes (Exp. 11/30/2023) & hand cleaner (Exp. 07/2020) 3. LI showed staff 2 expired items and she stated it was the only first aid kit on hand.
Plan of Correction:	As our plan of correction, Vienna Manor Administrator immediately reviewed with staff this regulation to ensure the first aid kit is up to date and all required items as well as no expired items. Administrator created a monthly check-off form log to ensure that the kit is not overlooked in the future. This update was made the day of the survey.
Standard #:	22VAC40-73-980-C
Description:	Based on record review and staff interview, the facility failed to ensure first aid kits are checked monthly. Evidence: 1. Staff 2 stated that she is unable to provide any evidence of a monthly check/log for the first aid kit.
Plan of Correction:	As our plan of correction, Vienna Manor Administrator created a monthly check-off form log to ensure that the kit is not overlooked in the future. This update was made the day of the survey.