VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Marian Manor
5345 Marian Lane
Virginia beach, VA 23462
(757) 456-5018

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: July 1, 2019 and July 2, 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 22VAC40-90 The Criminal History Record Report

Comments:

This was an unannounced renewal inspection conducted by two licensing inspectors from the Eastern Regional Office. The inspection took place on July 1, 2019 from 9:15 AM until 5:45 PM and on July 2, 2019 from 9:10 AM until 2:20 PM. There were 126 residents in care. The inspection consisted of a review of the above standard areas. During the inspection a tour of the building and grounds was conducted. Activities were observed to include a Bingo activity in the EAL sun room. Residents also attended a beach walk and a trip to a local store while inspectors were on site. A medication observation was conducted to include a check of the medication cart. Meals were observed as posted on the menu. Resident and staff records were reviewed, to include a review of criminal background checks for all new staff since the previous inspection. Resident and family interviews were also conducted. The following was discussed throughout the inspection: Admission and retention of residents with wounds as well as the physician?s determination of healing status, Documentation of the resident emergency exercises, Health care oversight evaluation of the residents who self-administer medications, Signatures for physician?s oral orders, Individualized Service Plans (ISPs) and Uniform Assessment Instruments (UAIs), First Aid certification for staff. Please complete your 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice. The plan of correction should indicate how the violation will be or has been corrected. Just writing the word 'corrected' is not acceptable. The plan of correction should include: 1. Step(s) to correct the non-compliance with the standard 2. Methods to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventive actions. If you have any questions please contact your inspector at 757-353-0430.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, the facility failed to ensure each direct care staff member who did not have current certification in first aid, received certification in first aid within 60 days of employment. Evidence: 1. On 07-02-2019, during staff #6?s record review with staff #1, staff #6 was hired as a Certified Nurse Aide (CNA) on 03-05-2019. Staff #6?s record did not contain a current first aid certification. 2. A review of the May 2019 and June 2019 staff work schedules provided by staff #3, documented staff #6 worked as a CNA on the following days: in May 2019: 6th, 7th, 9th- 12th, 15th-17th, 20th- 22nd, 24th-26th and 29th, and the following days in June 2019: 4th-9th, 11th-14th, 18th- 23rd ,and 25th-28th. 3. During interview on 07-02-2019, staff #1 acknowledged staff #6 did not receive certification in first aid within 60 days of employment.
Plan of Correction:	The correct certificate was obtained verifying that staff #6 was certified in First Aid in January, 2019. Certificate was obtained and placed on file. Administrative Assistant 7-2-19 Staff receiving this information upon hire and updating annually were in-serviced on what the correct certificate should look like to be sure that First Aid is included. 7-1-19 Employee files were audited for all nursing staff to assure that the correct certification and certificate are on file.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure the physical examination was completed within 30 days preceding a resident?s admission to the facility. Evidence: 1. During review of resident #10's record, the resident was admitted on 6-11-19. The physical examination report in the record was completed on 4-11-2019, 60 days prior to resident #10's admission to the facility. 2. During interview, staff #1 acknowledged the physical examination report was not completed within 30 days of the resident's admission.
Plan of Correction:	The physical was completed based on a visit that occurred outside of the 30-day window. This could not be corrected for resident #10 Admissions Coordinator was in-serviced on the requirement and reminded to check all dates on the form to assure that they fall in the 30-day window. 7-1-19 Executive Director and DON will check this date during pre-admission process to assure compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs. Evidence: 1. On 07-02-2019, during resident record review with staff #2 and staff #4, the following ISP?s did not include a description of the resident?s identified needs: a. Resident #2 has a physician?s order dated 05-02-2019 for PRN oxygen at 2L via nasal cannula; however, the ISP dated 05-12-2019 and the ISP dated 06-16-2019 did not include a description of the PRN oxygen. In addition, the current Uniform Assessment Instrument (UAI) on file dated 03-25-2019 documented the resident needs mechanical and physical assistance with dressing; however, the ISP?s did not include a description of the type of mechanical device that is used for dressing. b. Resident #4?s current UAI dated 04-10-2019 documented the resident needs mechanical and physical assistance with dressing and toileting; however, the current ISP dated 05-05-2019 did not include a description of the type of mechanical device that is used for dressing or toileting. 2. During interview, staff #2 and staff #4 acknowledged resident #2?s ISP?s dated 05-12-2019 and 06-16-2019, and resident#4?s ISP dated 05-05-2019 did not include a description of the residents? aforementioned needs.
Plan of Correction:	The ISPs in question were revised to include the information identified on the UAI as being a need by the IAL Nurse Coordinator. 7-3-19 All ISPs in this area were checked to be sure that the mechanical needs were identified correctly and revised as needed. 7-3-19 Staff certified in completing the ISPs were in-serviced on the proper way to identify needs on the UAI and include this information on the ISP to be sure that all resident needs are identified. DON 7-12-19 Once ISPs are completed, the FT Charge nurses, ADON, and DON will double check between the UAI and the ISP to assure that all needs are identified. On-going
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure the physician's oral orders were reviewed and signed by a physician within 14 days. Evidence: 1. On 07-01-2019, during resident #2?s record review with staff #2, the following physician?s oral orders did not contain a signature from the physician within 14 days of the order: a. An order dated 04-08-2019 for ?PRN: Oxygen at 2L/min via nasal cannula.... D/C continuous O20 changed to PRN.? b. An order dated 04-10-2019 to ?Apply Ted Hose daily in AM?? c. An order dated 04-15-2019 for ?Wound care to RLE? [right lower extremity]. d. An order dated 05-06-2019 for ?Diet change to puree consistency.? 2. During interview on 07-01-2019, staff #2 acknowledged resident #2?s aforementioned physician?s oral orders were not signed by the physician within 14 days and were not signed as of 07-01-2019.
Plan of Correction:	The hospice providers were educated to the requirements to have these orders signed within 14 days 7-1-19 Hospice providers developed a protocol to assure that orders are signed and tracked for signature to assure that the 14-day deadline is met 7-9-19 11-7 Charge Nurses are checking the charts for any unsigned orders, logs and tracks this information, and all shifts re-fax and follow up on these orders until a signature is obtained. Daily written report is given to the DON. 7-5-19 and on-going
Standard #:	22VAC40-73-680-C
Description:	Based on observation, record review, and interview, the facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. Evidence: 1. On 07-01-19 during the morning medication pass observation, staff #5 was unable to locate resident #6's Amlodipine Besylate 10mg on the cart for administration. The electronic Medication Administration Record (E-MAR) indicated the Amlodipine was scheduled for 9 AM. Staff #5 documented on the E-MAR that the medication was not available. 2. Resident #6's record contained a current physician's order dated 06-04-19 for "Amlodipine Besylate 10mg 1 tab daily for HTN". 3. During interview staff #2 acknowledged the medication was not available in the facility at the time of scheduled administration time. On 07-02-2019 staff #2 provided Licensing Inspector with a "Med Delivery" report indicating that resident #6's Amlodipine Besylate was administered late at 7:15 PM on 07-01-19.
Plan of Correction:	In-serviced Charge Nurses and Medication Aides on the new pharmacy hours and need to order medications within 7 days of needed refill 7-25-19 Med Carts will be checked weekly and during Medication pass observations to assure that refills are being requested 7 days prior to the medication running out 8-1-19 DON, ADON, ED The Eldermark dashboard will be monitored by the Charge Nurses, ADON and DON to assure medications are being administered on time 7-12-19 on-going