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: June 6, 2023 and June 7, 2023

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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 06/06/23 from 8:13 am to 2:35 pm and on 06/07/23 from 8:20 am to 1:15pm. 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: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: A medication pass observation was completed for five residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination and the report of such examination shall contain the following: results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Evidence: 1. The record for resident #5, admission date of 05/27/22, contains a TB risk assessment completed 05/30/22 which is after the resident?s admission date to the facility.
Plan of Correction:	Corrective Action for those Affected This problem was corrected 3 days after admission. What Steps Has Been Taken to Identify Other Residents with Potential to Be Affected Residents received their annual risk assessment during April, 2023. All newly admitted residents? records since April were audited for a risk assessment. Measures Put in Place or Systemic Changes to Prevent Recurrence A TB screening will be completed by the DON at the time of UAI completion. How Corrective Actions will be Monitored The History and Physical will be reviewed prior to admission to determine that a risk assessment is completed. The Director of Admissions, Director of Nursing and Executive Director will all check the document for completion. Date to Be Corrected/Staff Member Responsible The chart audit is completed and the new procedure of completing a TB risk assessment at the time of the UAI completion began on 6-19-23.
Standard #:	22VAC40-73-410-A
Description:	Based on the record review the facility failed to ensure upon admission the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative and such documentation shall be kept in the record?s record. Evidence: 1. The record for resident # 5, admission date of 05/27/22, does not contain documentation of completion of an orientation upon admission.
Plan of Correction:	Corrective Action for those Affected This problem was corrected a month after admission. What Steps Has Been Taken to Identify Other Residents with Potential to Be Affected Audit was done of new admissions in 2023 and any missing orientation forms completed by 6-16-23 Measures Put in Place or Systemic Changes to Prevent Recurrence Director of Admission will utilize and publish a tracker to assure orientation forms are received from managers within 7 days of admission beginning 6-16-23. How Corrective Actions will be Monitored Tracker will be shared amongst managers and follow up will be made by ED to assure timely completion. Date to Be Corrected/Staff Member Responsible Director of Admissions will establish and share tracker with managers. ED will enforce completion of the orientation.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) shall include a description of identified needs and the date identified. Evidence: 1. The record for resident #3 contains a physician order dated 04/02/23 to include ?assist with dressing each AM-Please supervise resident to wear clean clothing in the morning including underwear.? The resident?s ISP dated 09/19/22 documents the resident needs mechanical help only for dressing and does not include the need for assistance with supervision.
Plan of Correction:	Corrective Action for those Affected This problem was corrected for the identified resident on the day the issue was identified. What Steps Has Been Taken to Identify Other Residents with Potential to Be Affected UAI and ISPs will be audited over the next 3 months to ensure that the needs identified on the UAI are included on the Individual Service Plan. Measures Put in Place or Systemic Changes to Prevent Recurrence The ADON will use a tracker to check this upon completion of the ISP. How Corrective Actions will be Monitored The DON will review the UAI, ISP and tracker for completion. The ED will review these documents as well for accuracy. Date to Be Corrected/Staff Member Responsible The audit will take place over the next quarter and will be completed by October 1, 2023.
Standard #:	22VAC40-73-680-D
Description:	Based on observation the facility failed to ensure medications shall be administered in accordance with the physician?s instructions and consistent with standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. The record for resident #2 contains a physician order dated 05/16/23 for the following medications: Lactinex Granules 100MM PKT (packet) ?dissolve 1 packet in 8oz of water and drink by mouth twice daily for supplement.? Potassium CL ER MEQ Tablet ?take one tablet by mouth every morning for supplement.? During the medication pass observation, staff # 2 was observed to crush the Potassium Tablet, pour the Lactinex Granules 100MM packet into applesauce, and mix the crushed potassium and lactinex granules into applesauce. The resident?s record did not contain a physician order for medications to be crushed and the lactinex granules was not dissolved into water per the physician order instructions.
Plan of Correction:	Corrective Action for those Affected This problem was corrected for the identified resident on the day the issue was identified. What Steps Has Been Taken to Identify Other Residents with Potential to Be Affected In-service LPNs and Medication Aides on the importance of following the instructions on the MAR completely was completed 6-16-23. Medications cannot be crushed or placed in apple sauce without an order. Measures Put in Place or Systemic Changes to Prevent Recurrence The POS will contain an order for apple sauce as needed. An updated DO NOT CRUSH list was placed on each cart. How Corrective Actions will be Monitored Medication pass observations are completed 3-5x monthly and this will be monitored closely by the QA Nurse, ED, DON. Date to Be Corrected/Staff Member Responsible On-going
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. The record for resident #9 contains a DNR order dated 05/19/22 and a physician order dated 06/29/22 that documents a code status of DNR. The resident?s ISP dated 06/29/22 documents the resident?s code status as Full Code. 2. The record for resident #1 contains a DNR order dated 10/14/22. The resident?s ISP dated 08/22/22 documents the resident?s code status as Full Code. 3. The record for resident #7 contains a DNR order dated 02/23/22. The resident?s ISP dated 02/25/22 documents the resident?s code status as Full Code.
Plan of Correction:	Corrective Action for those Affected This problem was corrected for the identified residents on the day the issue was found. What Steps Has Been Taken to Identify Other Residents with Potential to Be Affected Audit of physician orders, face sheets, advanced directives, medical records, resident doors, DNR list, ISP, UAI and admission files was completed 6-19-23 and corrections implemented as needed. Measures Put in Place or Systemic Changes to Prevent Recurrence The 24-hour report will be utilized to document changes so all necessary staff are notified when current residents change their code status. The Director of Admissions will have the DNR paperwork completed prior to admission for residents who chose this option. How Corrective Actions will be Monitored ED will check the admission file on admission for this information and will also audit at care plan meetings Date to Be Corrected/Staff Member Responsible The audit was completed 6-19-23. The corrections will be completed by 6-26-23. ADON, DON, Director of Admissions and ED.