Inspection Report
Renewal
Census: 126
Deficiencies: 4
Jun 5, 2025
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found non-compliance with several standards including failure to update fall risk ratings after a fall, incomplete signatures on Individual Service Plans (ISP), expired medications in the medication cart, and medication administration record (MAR) errors including incorrect documentation of medication administration and omissions.
Deficiencies (4)
| Description |
|---|
| Facility did not ensure the fall risk rating was reviewed and updated after a fall. |
| ISP was not signed and dated by the resident or legal guardian. |
| Facility did not have a current and implemented written plan for medication management including proper disposal. |
| Medication Administration Record did not include medication errors or omissions. |
Report Facts
Residents present: 126
Resident records reviewed: 10
Staff records reviewed: 4
Resident interviews: 4
Staff interviews: 4
Expired medications identified: 3
Inspection duration hours: 6.83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and confirmed findings |
| Staff #7 | Confirmed lack of updated fall risk rating and medication administration errors | |
| Staff #6 | Confirmed missing signatures on ISP | |
| Staff #2 | Confirmed expired medications in medication cart |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Feb 25, 2025
Visit Reason
The inspection was conducted due to a complaint received by VDSS Division of Licensing on 2025-01-27 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint investigation related to Resident Care and Related Services; the allegations were not substantiated.
Report Facts
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the complaint investigation |
Inspection Report
Monitoring
Census: 62
Deficiencies: 4
Jun 4, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable regulations and standards at Marian Manor assisted living facility.
Findings
The inspection found multiple violations including failure to complete annual tuberculosis risk assessments for residents, missing signatures on individualized service plans, medication administration errors, and failure to obtain timely sworn statements from staff. Plans of correction were submitted and completed for all cited violations.
Deficiencies (4)
| Description |
|---|
| Failure to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident. |
| Failure to ensure individualized service plans (ISP) were signed and dated by the licensee, administrator, or resident/legal guardian. |
| Failure to ensure medications were administered in accordance with physician or prescriber instructions. |
| Failure to ensure a new sworn statement or affirmation was obtained within 30 days of hire for staff. |
Report Facts
Number of residents present: 62
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
Inspection Report
Renewal
Census: 120
Deficiencies: 5
Jun 6, 2023
Visit Reason
An unannounced renewal inspection was conducted on June 6 and June 7, 2023, to evaluate compliance with applicable standards and regulations for Marian Manor assisted living facility.
Findings
The inspection identified multiple violations related to admission physical examinations, resident orientation, individualized service plans, medication administration, and Do Not Resuscitate (DNR) orders. Corrective actions were implemented promptly for identified deficiencies, and systemic measures were put in place to prevent recurrence.
Deficiencies (5)
| Description |
|---|
| Failed to ensure a physical examination with TB risk assessment was completed within 30 days preceding admission. |
| Failed to provide orientation for new residents and their legal representatives upon admission, including emergency procedures and call system use. |
| Failed to ensure the individualized service plan included a description of identified needs and the date identified. |
| Failed to administer medications according to physician's instructions and standards of practice. |
| Failed to ensure valid written Do Not Resuscitate (DNR) orders were issued by attending physicians and included in individualized service plans. |
Report Facts
Number of residents present: 120
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews conducted: 4
Number of staff interviews conducted: 4
Number of residents observed during medication pass: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| Donesia Peoples | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Renewal
Census: 115
Deficiencies: 2
Jul 16, 2021
Visit Reason
A renewal inspection was initiated on 2021-07-08 and concluded on 2021-07-16 to review compliance with applicable standards and laws for Marian Manor.
Findings
The inspection identified non-compliances related to incomplete documentation in physical examination reports and Individualized Service Plans (ISP), specifically missing descriptions of allergic reactions and identified needs based on the Uniform Assessment Instrument (UAI).
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure the physical examination report documented the description of the person’s reaction to known allergies. |
| The facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs based upon the Uniform Assessment Instrument (UAI). |
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Census: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 101
Deficiencies: 1
Mar 11, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards.
Findings
The inspection found non-compliance related to the failure to document the description of a resident's reaction to known allergies in the physical examination report. The facility updated records and conducted staff in-service training to address this issue.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the physical examination report documented the description of the person’s reaction to known allergies. |
Report Facts
Inspection dates: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 21, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding medication administration at the facility.
Findings
The investigation, conducted remotely due to a state of emergency, found no evidence to support the allegation of non-compliance with standards or law.
Complaint Details
A complaint was received concerning medication administration. The investigation included record reviews and interviews, and the allegations were not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Conducted the complaint investigation and contacted the Administrator. |
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