Virginia DSS · Assisted Living Facility

Marian Manor

📍 5345 Marian Lane, Virginia Beach, VA, 23462

ID 10464Two Year licenseActive
8
Inspections
On record
5
With violations
Visits that cited something
3
Clean visits
Nothing cited
16
Violations cited
Individual findings
11
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Marian Manor was inspected 8 times between December 21, 2020 and June 5, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 16 violations under 11 distinct standards. 2 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 5 of these 8 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
08/01/2027
Administrator
Karen Land
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Assisted Living · Non-Ambulatory

Inspection History

8

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

June 5, 2026Inspection0 violations
Inspection dates
06/05/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/5/2026. from 11:00am-3:30pm. 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: 125 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed:4 Number of interviews conducted with residents:5 Number of interviews conducted with staff: 5 Observations by licensing inspector: Lunch and activity were observed. Water Temperature checks, Tour of buildings and Grounds, Call bell, Emergency Preparedness and Medication passes were completed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 5, 2025Inspection4 violations
Inspection dates
06/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 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
22VAC40-73-325-B
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
22VAC40-73-680-I
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
22VAC40-73-640-A
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
22VAC40-73-450-E
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.
February 25, 2025Complaint survey0 violations
Inspection dates
02/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/25/2025 1:30pm to 2:20pm. A complaint was received by VDSS Division of Licensing on 1/27/2025 regarding allegations in the area(s) of: Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: none Additional Comments/Discussion: The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 4, 2024Inspection4 violations
Inspection dates
06/04/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Admission, Retention And Discharge Of Residents Buildings And Ground
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 06/04/2024 at 08:00 am until 03:00 pm. 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: 62 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: 5 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: Breakfast, lunch and an activity were observed. A medication pass observation was completed for three 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. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident #5 contains a physician order dated 05/03/24 that includes “Digoxin 125mcg tablet, take 1 tablet by mouth daily for A-Fib, Hold if apical pulse is (less than) <60.” Resident’s #5 medication administration record (MAR) documents the resident was not administered Digoxin on the following dates when the resident’s Pulse was documented as being greater than 60: 05/05/24 and 05/11/24.
  2. The record for resident #1 contains a physician order dated 05/14/24 that includes “Calmoseptine, apply in intergluteal buttocks daily and as needed daily for redness excoriation.” Resident’s #1 MAR does not include documentation the resident was applied Calmoseptine daily on the following dates: 05/16/24 through 05/22/24; 05/25/24 through 05/30/24; 05/31.
Plan of correction
1) The medication administration time for resident #1s Calmoseptine was clarified and corrected by the Coordinator, on 6/4/2024. 2) The perimeters for resident #5s Digoxin was reviewed by the Medication Aides and nursing staff and additional medication aide training will be provided at the Medication Aide refresher training on 6/20/2024. 3) Each coordinator will perform an audit to review the Physician Orders against the Medication Administration Records (MAR) to assess for accuracy in the orders and on the MAR. 4) The 11-7 nurse, will check physician orders, against the MAR for completion and accuracy, nightly. The Coordinators will perform an audit of Physician orders against the MAR to ensure compliance with accuracy is achieved. Audits will occur weekly x4, then monthly x3. 5) The Director of Nursing, or designee, will review the audits and submit to the QA committee, for their review.
22VAC40-90-50-B
Based on the record review the facility did not ensure a new sworn statement or affirmation was obtained within 30 days of hire.
Evidence
  1. The record for staff #7 contains a sworn disclosure dated 3/10/23; the staff’s hire date is 10/27/23.
  2. Staff #8 verified that the sworn disclosure in the record was the most current document.
Plan of correction
1.) The sworn disclosure was completed by staff #7 and dated on the day of completion 6-4-24. 2.) Sworn disclosures will be audited as completed by the Administrative Assistant for the correct date. 3.) The Business manager will audit the date on sworn disclosures prior to filing the personnel file. 4.) All staff completed a sworn disclosure in the month of June as a part of the annual update.
22VAC40-73-320-B
Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as
Evidence
  1. d by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence:
  2. The record for resident # 1, contains a risk assessment for TB dated 4/26/23. The resident’s record did not contain an annual risk assessment for TB completed after 4/26/23.
  3. Staff # 1 confirmed the record for resident #1 did not contain an annual risk assessment for TB completed after 04/26/23.
  4. The record for resident # 2, contains a risk assessment for TB dated 4/21/23. The resident’s record did not contain an annual risk assessment for TB completed after 4/21/23.
  5. Staff # 1 confirmed the record for resident #2 did not contain an annual risk assessment for TB completed after 04/26/23.
Plan of correction
1) The risk assessment for TB was completed for residents #1 and #2, on 6/4/24. 2) An audit was completed by the Lynnhaven Cove Coordinator and QA Nurse to ensure each resident has an annual TB assessment completed. 3) Tickler process introduced to assure residents who were LOA/hospital/rehab are screened upon return. 4) Annual risk assessments are completed in May of each year and the QA nurse will audit upon completion that the assessment has been done. 5) The Director of Nursing or designee will review the audit and submit to the QA committee, for their review. Completed: 6/17/2024
22VAC40-73-450-E
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.
Evidence
  1. Resident’s #3 ISP dated 05/22/24 was not signed and dated by the resident, or the legal guardian.
  2. Resident’s # 4 ISP dated 06/02/24 was not signed and dated by the resident, or the legal guardian.
Plan of correction
1) The Individualized Service Plans (ISP’s) for residents #3 and #4 have been signed and dated, by the resident. 2) An audit will be performed, by the Coordinators to ensure each resident’s ISP has the appropriate signatures and dates for any updates that have been performed. 3) The Coordinators will perform audits to ensure updates have appropriate signatures and dates prior to being placed on the medical record. 4) The Director of Nursing, or designee, will review the audits and submit to the QA committee, for their review. Completed: 6/30/2024
June 6, 2023Inspection5 violations
Inspection dates
06/06/2023 & 06/07/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 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
22VAC40-73-450-C
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.
22VAC40-73-680-D
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
22VAC40-73-720-A
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.
22VAC40-73-410-A
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.
22VAC40-73-320-A
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.
July 14, 2021Inspection2 violations
Inspection dates
July 14, 2021 , July 15, 2021 and July 16, 2021
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 theinspection. The Administrator reported that the current census was 115. The inspector emailed the Administrator a list of items required tocomplete the remote documentation review portion of the inspection. The inspector reviewed 5 resident records, 5 staff records, staffschedules, 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 findingswere reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not availableduring the inspectionInformation gathered during the inspection determined non-compliances with applicable standards or law, and violations were documentedon the violation notice issued to the facility
Violations
22VAC40-73-320-A
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.
22VAC40-73-450-C
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
March 11, 2021Inspection1 violation
Inspection dates
March 11, 2021 , March 12, 2021 , March 16, 2021 , March 17, 2021 and March 18, 2021
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS
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 monitoring inspection was initiated on 3/11/21 and concluded on 3/18/21. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 101. The inspector emailed the Administrator the list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, and staff schedules submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-320-A
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 #3’s physical examination report dated 1/20/21 did not document a description of reaction to known allergy: Ampicillin.
  2. Staff #5 acknowledged Resident #3’s physical examination report dated 1/20/21 did not include the aforementioned information.
Plan of correction
The Medical Record was updated with this information for the resident after consulting with her family and her attending physician. Chart audit was conducted on all residents to check for reactions to known allergies and document reactions if they were not in the record. Charge Nurses and Medication Aides were in-serviced on the importance of having a reaction for any allergy documented in the medical record and on the MAR. The History and Physical will be reviewed closely prior to admission to determine that this information is documented. If allergies occur after admission, the medical record will include the reactions. Medication Aides and Charges Nurses were in-serviced to make sure that the reaction is included in the documentation. The Director of Admissions will follow up to obtain the missing reactions. The Director of Nursing and Executive Director will double check for completion on review.
December 21, 2020Complaint survey0 violations
Inspection dates
Dec. 21, 2020
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 complaint inspection was initiated on 12/21/2020 and concluded on 12/22/2020. A complaint was received by the department regarding allegations in the areas of medications administration. The Administrator was contacted by telephone to conduct the investigation. Records were reviewed and interviews were conducted. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.