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 14, 2021 , July 15, 2021 and July 16, 2021

Complaint Related: No

Areas Reviewed:

A renewal inspection was initiated on 7/08/21 and concluded on 7/16/21. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 115. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 5 resident records, 5 staff records, staff schedules, menu, and activities calendar submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/16/21. An exit interview was conducted with the Administrator on the date of the inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and discussion, the facility failed to ensure the physical examination report documented the description of the person?s reaction to known allergies. Evidence: 1. Resident #1?s physical examination report dated 4/23/21 did not document a description of reaction to known allergy: Tramadol. 2. Staff #6 acknowledged Resident #1?s physical examination report dated 4/23/21 did not included the aforementioned information.
Plan of Correction:	Corrective Action for those Affected: The medical record was updated with this information for the resident after consulting with her attending physician. What Steps Has Been Taken to Identify Other Residents with Potential to be Affected: Chart audit was conducted on all physical examinations to check for reactions to known allergies and document reactions if they were not in the record. The date this new or missing information was added was documented. Measures Put in Place or Systemic Changes to Prevent Recurrence: The history and physical will be reviewed closely prior to admission to determine that this information is documented. The Director of Admission, Director of Nursing and Executive Director will check the document for completion. How Corrective Actions will be monitored: The Director of Admissions will follow up tp obtain the missing reactions. The Director of Nursing and Executive Director will doublecheck for completion on review. Date to Be correct/Staff Member Responsible: The chart audit and corrections will be completed by August 5, 2021 by the Director of Admission and reviewed by the QA Nurse and DON.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and discussion, the facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs based upon the Uniform Assessment Instrument (UAI). Evidence: 1. Resident # 5?s UAI dated 2/28/21 documented mechanical help with mobility. The resident?s ISP dated 2/28/21 did not document the need. 2. Staff #6 acknowledged Resident #5?s ISP dated 2/28/21 did not document mechanical help with mobility.
Plan of Correction:	Corrective Action for those Affected: ISP was revised to include identified need (Mechanical help with mobility with use of rollator) on UAI. Presented revised ISP and explained to resident and signed by resident and interdisciplinary team. What Steps Has Been Taken to Identify Other Residents with Potential to Be Affected: 100% Review of UAI and ISP for all residents. Measures Put in Place or Systemic Changes to Prevent Recurrence: DON to review formulation of ISP process with ADON, Charge Nurses and QI staff on identifying all needs on UA and address on ISP. DON to review to ensure accuracy identified and ISP are matching then submitted to ED. How Corrective Action Will Be Monitored: Use of UAI/ISP Comparison Worksheet on reviewing UAI and ISP by ADON on formulating care plan. DON to use same tool on 2nd check of UAI and ISP to ensure accuracy that all identified needs are addressed on the ISP. Date to be Corrected/Staff Member Responsible: ADON, DON, ED, QI Nurse