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: Dec. 7, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES XX 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 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 22VAC40-73 EMERGENCY PREPAREDNESS 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

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: 12-07-2022, 11:00 a.m. ? 2:30 p.m. 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: 117 Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication pass, activity, emergency food and water, water temperatures, kitchen, meal, records. 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 #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure verification that the staff person has received a copy of his current job description, as well as completed documentation of orientation and training for staff. Evidence: 1. Staff #2?s date of hire was 11-02-2021. There was no verification in Staff #2?s record that the staff received a copy of the current job description. Additionally, Staff #2's record did not contain documentation of orientation in the record. 2. Staff #4?s date of hire was 9-13-2022. Staff #4's record did not contain documentation of orientation in the record.
Plan of Correction:	Copy of job description was found in file in wrong place Copy of signed orientation was found #2 and #4 in the employee records
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there is a significant change in the resident's condition. Evidence: 1. Resident #3 admitted 4-09-2019. Resident #3?s UAI dated 5-11-2022 documented, ?appropriate? under behavior pattern; however, Resident #3?s ISP dated 6-02-2022 documented, ?wander and/or elopement behavior? I wonder continuously and demonstrate exit-seeking behavior.? 2. Resident #7 admitted 3-31-2021. Resident #7?s UAI dated 11-23-2022 documented, ?appropriate? under behavior pattern; however, Resident #7?s ISP dated 11-23-2022 documented, ?wander and/or elopement behavior? I wander inside the community but do not leave the building. I can easily be redirected. I may be confused at times and may be a potential for unintended exit.?
Plan of Correction:	Resident record updated. Ed will review all ISP?s and UAI?s for residents reviewed in at risk meeting making sure they reflect any changes and concerns discussed.
Standard #:	22VAC40-73-450-A
Description:	Based on record review and interview with staff, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. Resident #2 admitted 11-03-2022. There was no preliminary plan of care in the record; and the comprehensive individualized service plan was dated 12-09-2022. 2. Staff #1 confirmed during interview that Resident #2?s ISP was not completed at or prior to admission.
Plan of Correction:	Resident record was corrected 1/12/23. ED will follow up with chart on day of resident admission that Preliminary care plan is completed and in the resident record