VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Morningside of Bellgrade
2800 Polo Parkway
Midlothian, VA 23113
(804) 379-2800

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Oct. 21, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION XX 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS XX 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND XX 22VAC40-73 EMERGENCY PREPAREDNESS XX 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 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 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

Activities calendar time codes Date on TB screening

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: 10-21-2022, 9:00 a.m. - noon The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on record review, the facility failed to shall document that the order of priority specified in subsection A (The resident, if capable of making an informed decision; A guardian or other legal representative for the resident if one has been appointed; 3. A relative who is willing and able to take responsibility to act as the resident's representative??) of this section was followed, and the documentation shall be retained in the resident's file. Evidence: 1. Resident #5 admitted 9-03-2021 to the facility. Resident #5?s ?Approval for Placement in Special Care Unit? dated 10-18-2021 did not document ?Explanation of why written approval was not obtained from each individual higher on the list of priority? that was checked for ?Guardian or legal representative for the resident? and ?adult child?.
Plan of Correction:	Resident #5 Placement form has been updated to reflect the reason why POA/Child admitted versus self. All charts of our memory care residents were reviewed to make sure in compliance
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure the resident?s physical examination documented a description of the person?s reaction to any known allergies. Evidence: 1. Resident #7 admitted 9-30-2022. Resident #7?s Report of Resident Physical Examination dated 9-22-2022 documented the resident has allergies to Iodine, Nsaids (Nonsteroidal anti-inflammatory drugs), and Seafood; however, no reactions to allergies were documented.
Plan of Correction:	Resident #7 interviewed for reactions to known allergens, chart updated 12/9/22. DON reviewing all resident charts for allergy reactions.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the UAI. Evidence: 1. Resident #3 admitted 1-31-2022. Resident #3?s UAI dated 1-24-2022 documented mechanical help with bathing, toileting, walking and stairclimbing; however, the resident?s ISP dated 2-10-2022 did not address mechanical help with these four needs. 2. Resident #5 admitted 9-03-2021. Resident #5?s uniform assessment instrument (UAI) dated 9-22-2022 documented the resident requires mechanical and human help, supervision with bathing and dressing; however, the resident?s most current ISP (not dated) did not identify mechanical help with bathing or dressing needs. 3. Resident #8 admitted 6-30-2022. Resident #8?s UAI dated 9-26-2022 documented the resident is incontinent of bowel and bladder ?weekly or more?; however, the resident?s ISP dated 10-20-2022 did not document bowel and bladder needs. 4. Resident #10 admitted 1-14-2021. Resident #10?s UAI dated 2-10-2022 documented the resident is continent of bowel and bladder ?less than weekly?; however, the resident?s ISP dated 2-10-2022 did not document bowel and bladder needs. 5. Resident #11 admitted 1-14-2020. Resident #11?s UAI dated 5-12-2022 documented the resident requires mechanical and human help with bathing; however, the resident?s ISP dated 5-21-2022 did not identify mechanical help with bathing needs. Additionally, the UAI documented the resident is continent of bowel and bladder ?less than weekly?; however, the resident?s ISP did not document bowel and bladder needs.
Plan of Correction:	Resident charts were reviewed and verified to make sure UAI information matched the ISP. Going forward all ISP?s will be reviewed by two nurses to verify all information is captured on ISP from the UAI
Standard #:	22VAC40-73-450-E
Description:	Based on record review and interview with staff, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. The following resident?s ISPs were not signed and dated by the resident or responsible party: a. Resident #3 admitted 1-31-2022. Resident #3?s ISP was dated 2-10-2022. b. Resident #5 admitted 9-03-2021. Resident #5?s ISP was signed by a staff member but was not dated by the facility representative, nor signed and dated by the resident or responsible party. c. Resident #6 admitted 1-31-2021. Resident #6?s ISP was dated 9-16-2022. d. Resident #7 admitted 9-30-2022. Resident #7?s ISP was dated 9-30-2022. e. Resident #8 admitted 6-30-2022. Resident #8?s ISP was dated 10-20-2022. f. Resident #9 admitted 10-02-2020. Resident #9?s ISP was dated 5-12-2022. g. Resident #10 admitted 1-14-2021. Resident #10?s ISP was dated 2-10-2022. h. Resident #11 admitted 1-14-2020. Resident #11?s ISP was dated 5-21-2022.
Plan of Correction:	Families have been reached out to via phone and email with a completion date of 12/22/2022 given. Going forward documentation of the attempts. Or allowance for email acceptance will be allowed, and copies of emails, letters, ect will be attached to the ISP forms
Standard #:	22VAC40-73-520-I
Description:	Based on observation and interview with staff, the facility failed to ensure the written schedule of activities documented a substitution of activity change on the schedule. Evidence: 1. Licensing inspector observed on 10-21-2022 at approximately 11:00 a.m. that residents of the safe, secure environment (SSE) in the living room area watching television; however, the activity calendar documented a ?resident outing? was taking place at that time. 2. Staff #1 confirmed during interview that no outing took place and another activity was substituted.
Plan of Correction:	Safe and Secure manager reviewed policy on documenting changes to activities schedule. 12/8/2022. Executive Director will spot check calendar for changes and proper documentation.
Standard #:	22VAC40-73-680-B
Description:	Based on observation, record review, and interview with staff, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. On 10-21-2022 at approximately 11:05 a.m. during the medication administration observation with Staff #2, around 10-11 pills were observed in a small plastic cup in the Resident #1?s room on the table. 2. Staff #2 stated that Resident #1 took all the morning medications prescribed to the resident and believes that these medications were left over from the evening on 10-20-2022. 3. Resident #1 is prescribed the following evening medications according to the most recent signed physician?s orders dated 10-13-2022: Acetaminophen, Buspirone, Carvedilol, Donepezil, Isosorbide, Melatonin, Memantine, Oyster Shell Calcium, Preservision, Sertraline, and Tramadol. Each medication was signed off as administered.
Plan of Correction:	Staff person responsible was identified and removed from cart until completion of 8 hours of retraining. 10/23 4 hours, 10/24 four hours Staff person will be monitored for compliance with standards in communities cart audits for 6 months.
Standard #:	22VAC40-73-960-B
Description:	Based on observation, the facility failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, or telephones. Evidence: 1. The second floor fire and emergency evacuation drawing did not document telephones, primary and secondary evacuation routes, or areas of refuge. 2. Photographic evidence was obtained.
Plan of Correction:	Temporary fix, hand written on emergency plan the required information, 12/8. New form ordered 12/9/22