VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: June 5, 2025

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 63.2 GENERAL PROVISIONS 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: 06/05/2025 8:30am to 3:20pm. Number of residents present at the facility at the beginning of the inspection: 126 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:4 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. Additional Comments/Discussion: 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on the record review the facility did not ensure the fall risk rating shall be reviewed and updated after a fall. Evidence: 1. The record for resident #1 contains a progress note documenting the resident experienced a fall on 03/07/2025. Resident #1?s record contains a fall risk rating dated 02/12/2025 and was not updated after the resident?s fall that occurred on 03/07/2025. 2. Staff #7 confirmed the record for resident #1 did not contain documentation of a fall risk rating completed after the fall on 03/07/2025.
Plan of Correction:	Fall Risk was completed for Resident #1 on 6/6/25, all charts audited for any missing fall risk assessments by 7/1/25, QA nurse will check for the fall risk assessment weekly on all fall incidents on-going
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility did not ensure the ISP shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. The record for resident #2 contains an ISP that includes an initiated date of 05/16/2025 however the ISP does not include the signature of the resident or the legal guardian. 2. Staff #6 confirms the ISP does not include the signature of the resident or the legal guardian.
Plan of Correction:	Resident and POA signed the ISP on 6/6/25. ISP for new admissions will be signed by resident or POA within the first 7 days of admission. All charts were audited for any missing signatures and signatures obtained. Care plan coordinator will be responsible for this on-going.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and a review of the facility?s Medication Administration Record, it was determined that the facility did not ensure that the facility shall have, keep current, and implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and shall include a plan for proper disposal of medication. Evidence: 1. During a review of the medication cart on 06/05/2025, it was determined that Resident #8?s Clonidine HCL 0.1mg expired on 05/31/2025. 2. During a review of the medication cart on 06/05/2025, it was determined that Resident #9?s Docusate Sodium 100mg expired on 05/31/2025. 3. During a review of the medication cart on 06/05/2025, it was determined that Resident #10 Acetaminophen 325 mg expired on 05/31/2025. 4. During the review of the medication cart on 06/05/2025, Staff #2 confirms the medications were expired.
Plan of Correction:	All 7 med carts audited for expired medications on 6/7/25. Medication Aides attended refresher course on 6/18/25 to review the importance of checking for expired medications on an on-going basis. 11-7 Medication Aides will complete weekly audits to check for expired medications and submit to DON for review. QA Nurse will continue to check carts on a monthly basis. Beginning 6/22/25 and on-going
Standard #:	22VAC40-73-680-I
Description:	Based on observation and a review of the facility?s Medication Administration Record, it was determined that the facility did not ensure that the MAR shall include Any medication errors or omissions. Evidence: 1. A review of the Physicians order indicated Pantoprazole 40 mg to be administered every morning for GERD for Resident #2, however on 05/16/2025 the medication was signed as administered at the following times: Pantoprazole Sodium 40 mg (8:00pm), (9:00pm). 2. During an interview on 06/05/25 with staff #7, Staff #7 confirmed the medication for Resident #2 were signed by the staff administering medications in error. 3. Resident?s #4 May 2025 MAR does not include reason for omissions and staff initials for the following two treatments scheduled at 12 am on the dates of 05/07/25, 05/11/25, 05/12/25, and 05/20/25: Geri sleeve to bilateral lower extremities each shift for prevention; Monitor surgical site to right hip for signs of infection. 4. During an interview on 06/05/25 with staff #7, staff #7 acknowledged the MAR for resident #4 did not include reason for omissions and staff initials indicating the following two treatments was completed as scheduled at 12 am on the dates of 05/07/25, 05/11/25, 05/12/25, and 05/20/25:Geri sleeve to bilateral lower extremities each shift for prevention; monitor surgical site to right hip for signs of infection.
Plan of Correction:	Order for resident #2 was transmitted incorrectly on the MAR. This was corrected on 6/16/25. Medication Aides reviewed the process for administering medications (5 Rights) at the 4-hour refresher on 6/18/25 including review of medication violations from recent inspection. Charge Nurse transcribing new orders will be checked by the charge nurse on the following shift to assure accuracy. Beginning 6/23/25 and on-going Each charge nurse will print the missed meds report per shift to assure medications are being given in a timely manner and address any issues that may need attention. These reports will be checked daily by the DON and ED and any issues will be addressed. Beginning 6/23/25 and on-going