VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vienna Manor V, LLC
1416 Carrington Lane
Vienna, VA 22182
(703) 493-1150

Current Inspector: Alexandra Roberts

Inspection Date: Jan. 27, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A complaint was received by VDSS Division of Licensing on 1/17/2023 regarding allegations in the area of resident care. The evidence gathered during the investigation supported some, but not all of the allegations; area of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on documentation review and interview the facility failed to ensure that the comprehensive Individualized Service Plan (ISP) shall include a written description of what services will be provided to address identified needs and who will provide them. Evidence: Resident #1?s most recent ISP dated 10/12/2023 did not include details regarding the assessed need for assistance with an in-dwelling Foley catheter or who shall perform what tasks regarding its maintenance.
Plan of Correction:	Administrator will ensure that all resident ISPs included of the resident?s assessed needs.
Standard #:	22VAC40-73-560-E
Complaint related:	No
Description:	Based on documentation review and interview the facility failed to ensure that all resident records shall be kept current. Evidence: On 12/23/2022 a Resident #1 tested positive for Covid in the facility. The Administrator verbally stated that all staff and residents were consequently given Covid tests however there is no documentation regarding the application or results of the testing.
Plan of Correction:	Administrator will ensure that all testing will be documented in the resident record