VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vienna Manor IV, LLC
3903 Estel Road
Fairfax, VA 22031
(703) 218-1891

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: June 3, 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 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Technical Assistance:

First Aid Kit Supplies/ Logs, Incident Reports

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/03/2024: 8:15 AM to 11:30 AM 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: 2. Number of staff records reviewed: 2. Number of interviews conducted with residents: 2. Number of interviews conducted with staff: 2. Observations by licensing inspector: Meals, Activities, Medication Pass 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on facility record review and staff interview, the facility failed to ensure the disclosure statement was on the form developed by the department. Evidence: 1. Staff 2 provided the Disclosure Statement to the licensing inspector. 2. The Disclosure statement form was edited to exclude the first paragraph on page 1, the footers on all pages, and the formatting for the entire document had been adjusted. 3. Staff 1 confirmed that they had modified the original department form.
Plan of Correction:	The Disclosure Statement immediately transferred to VA DSS Template form as required by the Department. Vienna Manor will officially use the form developed by the DSS.
Standard #:	22VAC40-73-620-B
Description:	Based on facility record review and staff interview, the facility failed to ensure that the special diet oversight was certified that the requirements of the standards were met. Evidence: 1. The dietician oversight, dated 01/26/20243, did not contain certification that the requirements of the standard are met. 2. Staff 1 confirmed that the special diet oversight did not contain certification that the requirements of the standard were met.
Plan of Correction:	The Administrator Immediately Notified our Registered Dietitian to include the Statement ?Certification of the VA DSS Standards were met? on her final report for Special Diet Oversight. Vienna Manor Registered Dietitian updated her report to reflect the VA DSS Standard on Special Diet.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure that orders, written and oral contained the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident 1?s physician orders, dated 05/30/2024, contained an order for oxygen stating the following: ?DC Oxygen and restart only if pulse at <88 or respiratory distress (resting rate > 24/min).? 2. Staff 2 confirmed the order did not state the route, dosage, or how often the medication is given.
Plan of Correction:	Our MT left a clarification order to her MD on 5/31/24 (Friday evening) for missing indication and route for the Oxygen treatment. The Administrator immediately contacted the Physician and Received the clarification ?Oxygen @ @LPM for SOB via NC? on 6/3/2024. Telephone order was signed and received 6/6/2024
Standard #:	22VAC40-73-950-F
Description:	Based on facility record review and staff interview, the facility failed to ensure the emergency preparedness plan was reviewed annually and documented by signing and dating the plan. Evidence: 1. Staff 2 provided the ?Emergency and Fire Plan.? 2. The plan is undated and unsigned. 3. Staff 1 confirmed this plan was created in 2019 and has not been reviewed or approved since.
Plan of Correction:	The Administrator immediately contacted the Local Disaster Coordinator to visit and review our Emergency Preparedness and Response Plan annually. The Administrator had spoken and discussed some future training for all Vienna Manor locations.
Standard #:	22VAC40-73-960-A
Description:	Based on facility record review, the facility failed to ensure the fire and emergency evacuation plan was approved by the appropriate fire official. Evidence: 1. The Fire Safety and Evacuation Plan was provided by Staff 2. 2. The Fire Safety and Evacuation Plan was undated, and there was a note that says ?w/ FFX CITY FOR REVIEW AND APPROVAL.? 3. There was no documentation that the plan was approved by the appropriate fire official. Staff 1 confirmed they did not have the documentation it was approved by the appropriate fire official in the record on site as of the date of inspection.
Plan of Correction:	Fire and Emergency Plan was approved by Fire Marshall back in 2019, as part of their requirements before we obtained our Facility License. The Administrator immediately notified the local Fire Marshall to stamped our Fire and Emergency Plan that was approved back in 2019. The Administrator received the stamped copy of the Fire and Emergency Plan as of June 5,2019.
Standard #:	22VAC40-73-980-H
Description:	Based on direct observation and staff interview, the facility failed to ensure that 48 hours of emergency drinking water was available and maintained on site at any given times. Evidence: 1. Staff 2 showed the licensing inspector storage of emergency food and water. 2. 1 case of water including 15 bottles of 10oz water was available on site for emergency drinking water. 3. Staff 1 confirmed that the full supply was kept off site about 3 miles away at a secondary location due to a lack of storage.
Plan of Correction:	Vienna Manor stored 96 hours of water supply off site, at our secondary location. The Administrator immediately relocated 48 hours of drinking water to this location as required by VA DSS.