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 2, 2020

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.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/2/20 and concluded on 6/4/20. The administrator's designee was contacted by telephone to initiate the inspection. The designee reported that the current census was seven. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and the violation was documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that each resident's physical examination contained all of the required information. Evidence: The physical examination for Resident #1, dated 12/20/19, was observed during the inspection. The physical examination form stated that the resident was allergic to: ampicillin, sulfa-drugs, Pyridium, and Keflex. The form did not list Resident #1's reactions to the allergens. The physical examination for Resident #2, dated 11/27/19, was observed during the inspection. The physical examination form stated that Resident #2 was allergic to Codeine. The form did not list Resident #2's reaction to the allergen.
Plan of Correction:	The administrator contacted the Physician immediately and verified resident's # 2 allergic reaction to codeine. The reaction to codeine immediately added to her report of physical examination form per physician instruction. Vienna manor's Nurse will review report of physical exam prior to admission to make sure all information are completed by their Physician.