Vienna Manor IV, LLC

Based on resident record review and staff interview, the facility failed to ensure that the resident personal/social data was acquired prior to admission and kept current. Evidence: 1. Resident 1?s, admitted 03/19/2025, record did not contain all the required personal/ social data. 2. Resident 2?s, admitted 11/04/2024, record did not contain all the required personal/ social data. 3. In an interview with the LI on 04/18/2025, staff 1 stated that all personal/social data was collected in the Resident Biography or the Resident Information Form, Staff 1 confirmed that the required personal/social data was not captured on those forms.

Based on direct observation and staff interview, the facility failed to ensure that all doors leading to the outside always remained unlocked to ensure freedom of movement. Evidence: 1. During a tour of the facility on 04/18/2025, the Licensing Inspector (LI) observed three locked doors leading to the outside. All three doors featured three locks ? a doorknob, a deadbolt, and a sliding security latch. 2. In three separate interviews with the LI on 04/10/2025, Staff 1, Staff 2, and Staff 3 confirmed that the doors always remain locked. Both Staff 2 and Staff 3 confirmed they did not have residents with exit seeking or wandering behaviors. Staff 2 stated the facility had planned, supervised outside time for residents that wanted to leave. Staff 3 stated that residents can leave with family if requested. 3. Photo evidence obtained.

Based on facility document review and staff interview, the facility failed to ensure that fire drills were held on all shifts within a quarter. Evidence: 1. The LI reviewed the Record of Required Fire and Emergency Drills. The drills were held on the following dates and times: a. 08/05/2024 at 11:00 a.m. b. 09/05/2024 at 9:00 a.m. c. 10/07/2024 at 2:00 p.m. d. 11/7/2024 at 10:00 a.m. e. 12/03/2024 at 2:00 p.m. f. 01/02/2025 at 10:00 a.m. g. 02/03/2025 at 3:00 p.m. h. 03/10/2025 at 11:00 a.m. i. 04/02/2025 at 2:00 p.m. 2. In three separate interviews with the LI on 4/10/2025, Staff 1, Staff 2, and Staff 3 confirmed that the facility operates with two scheduled shifts ? 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. Staff 1 confirmed that the drills were not held on the second shift.

Based on resident record review, staff record review, and staff interview, the facility failed to ensure when residents of a mixed population are present, there was at least two direct care staff members always awake and on duty in each building who were responsible for the care and supervision of the residents. Evidence: 1. The facility?s census on 11/25/2024 was 8 residents. 2. Resident 1?s, admitted 06/01/2023, record contains a ?Report of Resident Physical Examination? completed on 05/25/2023 that lists the diagnosis ?Advanced Dementia.? 3. Resident 3?s, admitted 11/04/2024, record contains a ?Report of Resident Physical Examination? completed on 11/04/2024 that lists the diagnosis ??Dementia?Anxiety.? 4. Resident 4?s, admitted 12/26/2019, record contains physician orders, signed 10/21/2024, that list Resident 4?s diagnosis as ?Dementia?Short Term Memory Loss...? 5. Resident 5?s, admitted 01/18/2024, record contains a ?Report of Resident Physical Examination? completed on 01/15/2024 that lists the diagnosis as ?Dementia c Psychosis.? Resident 5?s physician orders, dated 10/21/2024, list Resident 5?s diagnosis as ??Dementia?Psychosis?? 6. Resident 6?s, admitted 12/23/2019, record contains a ?report of Resident Physical Examination? completed on 10/23/2029 that lists the diagnosis as ?Mild Dementia?? Resident 6?s physician orders, dated 10/21/2024, list Resident 6?s diagnosis as ?Mild Dementia??? 7. Resident 7?s, admitted 10/04/2021, record contains a ?Report of Resident Physical Examination? dated 10/03/2021 that lists the diagnosis as ??Alz.? Resident 7?s physician orders, dated 10/25/2024, lists Resident 7?s diagnosis as ??Dementia?Agitation.? 8. Resident 8?s, admitted12/21/2019, record contains a ?Report of Resident Physical Examination? dated 11/27/2021 that lists the diagnosis as ?Dementia?? Resident 8?s physician orders, dated 10/21/2024, list Resident 8?s diagnosis as ??Dementia; anxiety/agitation; confusion?? 9. Resident 9?s, admitted 02/07/2023, record contains a ?Report of Resident Physical Examination? dated 01/26/2023 that lists the diagnosis as ?Severe Alzheimer?s?? Resident 9?s physician orders, signed 10/21/2024, listed Resident 9?s diagnosis as? ?Vascular dementia?Alzheimer?s?Agitation?? 10. The LI was provided the schedule for 06/24/2024 through 11/25/2024. On all dates, there was only one scheduled staff member during the nighttime hours. 11. Staff 2 stated that there was no punch in logs for staff. Staff 2 confirmed the schedule is accurate and reflects hours worked. Staff 1 and Staff 2 confirmed that both Staff 1 and Staff 2 were on call every night and were within 10 minutes of the facility to provide support as needed.

Based on staff record review and staff interview, the facility failed to ensure that direct care staff working with a mixed population attended six hours of training in working with individuals who have cognitive impairment within four months of the starting date of employment. Evidence: 1. Staff 3?s, hired 10/13/2023, did not contain six (6) hours of training in working with individuals who have cognitive impairment. 2. Staff 2 confirmed Staff 3 did not have six (6) hours of training in working with individuals who have cognitive impairment.

Based on resident record review and staff interview, the facility failed to ensure that the disclosure statement was prepared on the department form. Evidence: 1. Resident 3?s, admitted 11/04/2024, record contained a disclosure statement signed on 11/04/2024. 2. The disclosure statement contained additional information on pages four (4) and five (5) beyond what is requested on the department prepared form including schedule of charges, health care center admission, special services and supplies, trusted third party partners and services available at Vienna Manor, miscellaneous provisions, refund of sums paid in advance, visiting, personal laundry service, and liability insurance. 3. In an interview with the LI on 11/25/2024. Staff 2 confirmed there was additional information on the disclosure statement signed on 11/04/2024. 4. In an email to the LI on 11/27/2024, Staff 2 stated ?Also? just FYI. You have cited us twice for disclosure this year.? 5. On 06/26/2024, Staff 2 signed the inspection reports from 06/03/2024 and agreed to the facility submitted plan of correction that stated ?The Disclosure Statement immediately transferred to VA DSS Template form as required by the Department. Vienna Manor will officially use the form developed by the DSS.? The date to be corrected was 06/04/2024.

Based on facility document review and staff interview, the facility failed to ensure that a written staffing plan that specifies the number and type of staff required to meet the day to day, routine direct care needs and any identified special needs for the residents in care. Evidence: 1. Staff 2 provided a copy of the ?Vienna Manor Assisted Living Staffing Plan.? 2. The ?Vienna Manor Assisted Living Staffing Plan? does not specify the number and type of staff required to meet the day to day, routine direct care needs and any identified special needs for the residents in care. 3. Staff 1 confirmed that the written staffing plan did not include the specific number and type of staff.

Based on resident record review and staff interview, the facility failed to ensure that reassessments due to a significant change in a resident?s condition, using the UAI

Based on direct observation and staff interview, the facility failed to ensure that a staff person was available to adequately lead the activity, assist the residents with the activity, supervise the general area, redirect any residents that require different activities, and protect the health, safety, and welfare of the residents participating in the activity. Evidence: 1. On 11/25/2024, the LI observed two scheduled activities including Mindful Movement at 10:00 AM and Community Choir at 11:00 AM. Both Mindful Movements and Community Choir used television videos to complete the activities. During the activity, Staff 1 was providing care to various residents and moving in and out of the activity room to provide care, administer medication, and provide documentation to the LI. Staff 4 was providing care to residents and started cooking lunch around 11:00 AM. Both Staff 1 and Staff 2 would intermittently step into the activity room, provide words of encouragement or participate, and then leave the room. 2. In an interview with the LI on 11/25/2024, Staff 1 confirmed that they were providing care to the residents and stated that Staff 4 was cooking lunch for a portion of the activities. Staff 2 stated that the residents were in view from the kitchen, and that the expectation is that staff are in eyesight of the residents even if they are not able to interact with the residents.

Based on facility record review and staff interview, the facility failed to ensure the disclosure statement was on the form developed by the department. Evidence: 1. Staff 2 provided the Disclosure Statement to the licensing inspector. 2. The Disclosure statement form was edited to exclude the first paragraph on page 1, the footers on all pages, and the formatting for the entire document had been adjusted. 3. Staff 1 confirmed that they had modified the original department form.

Based on facility record review and staff interview, the facility failed to ensure that the special diet oversight was certified that the requirements of the standards were met. Evidence: 1. The dietician oversight, dated 01/26/20243, did not contain certification that the requirements of the standard are met. 2. Staff 1 confirmed that the special diet oversight did not contain certification that the requirements of the standard were met.

Based on record review and staff interview, the facility failed to ensure that orders, written and oral contained the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident 1?s physician orders, dated 05/30/2024, contained an order for oxygen stating the following: ?DC Oxygen and restart only if pulse at <88 or respiratory distress (resting rate > 24/min).? 2. Staff 2 confirmed the order did not state the route, dosage, or how often the medication is given.

Based on facility record review and staff interview, the facility failed to ensure the emergency preparedness plan was reviewed annually and documented by signing and dating the plan. Evidence: 1. Staff 2 provided the ?Emergency and Fire Plan.? 2. The plan is undated and unsigned. 3. Staff 1 confirmed this plan was created in 2019 and has not been reviewed or approved since.

Based on facility record review, the facility failed to ensure the fire and emergency evacuation plan was approved by the appropriate fire official. Evidence: 1. The Fire Safety and Evacuation Plan was provided by Staff 2. 2. The Fire Safety and Evacuation Plan was undated, and there was a note that says ?w/ FFX CITY FOR REVIEW AND APPROVAL.? 3. There was no documentation that the plan was approved by the appropriate fire official. Staff 1 confirmed they did not have the documentation it was approved by the appropriate fire official in the record on site as of the date of inspection.

Based on direct observation and staff interview, the facility failed to ensure that 48 hours of emergency drinking water was available and maintained on site at any given times. Evidence: 1. Staff 2 showed the licensing inspector storage of emergency food and water. 2. 1 case of water including 15 bottles of 10oz water was available on site for emergency drinking water. 3. Staff 1 confirmed that the full supply was kept off site about 3 miles away at a secondary location due to a lack of storage.

Based on record review, the facility failed to ensure that each staff member submits, on or within seven days prior to the first day of work at the facility, the results of a tuberculosis risk assessment documenting the absence of tuberculosis in a communicable form. The risk assessment shall be no older than 30 days. Evidence: The record for Staff #1, hired 8/9/21, was reviewed during the inspection. Staff #1's orientation form and the facility's work schedule listed 8/9/21 as Staff #1's first day of work. Staff #1's tuberculosis risk assessment was dated 8/11/21. Staff #1's risk assessment was not submitted on or within seven days, prior to her first day of work at the facility.

Based on record review and interview, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment. Evidence: The record for Staff #2, hired 12/24/19, was reviewed during the inspection. Staff #2's first aid certification expired on 1/24/22. No additional documentation was provided during the inspection. Facility staff confirmed that Staff #2 did not have current first aid certification from an approved provider. The record for Staff #3, hired 6/1/21, was reviewed during the inspection. Staff #3's record contained first aid certification that was completed on 9/7/21. Staff #3's first aid certification was not received within 60 days of her employment.

Based on record review and documentation, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter. Evidence: Resident #1's Uniform Assessment Instrument ( UAI

Based on record review and interview, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1's May 2021 Medication Administration Record ( MAR

Based on record review and interview, the facility failed to ensure that medical treatments ordered by a physician or other prescriber are provided according to their instructions and documented in the resident record. Evidence: The August MAR

Based on record review, the facility failed to ensure that the MAR