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: June 21, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 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: 6/21/2024 9:50a ? 5:00p 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: 102 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: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: Meals, Dining, Activities, Postings, Resident Rooms, Kitchen, Medication, 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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1080-B
Description:	Upon review of resident records, the facility failed to obtain written approval for a resident to reside in a safe, secure environment in a special care unit. Evidence: Resident #1 was admitted to the facility on 11/18/14 and an assessment dated 8/9/15 indicates that they had a serious cognitive impairment. The date the resident was admitted to the unit is unclear and approval following the order of priority for residence in the unit was not documented in the resident record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-1110-B
Description:	Based on a review of resident records the facility failed to perform a six month or annual review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: Resident #1 has resided in the special care unit since 2015 (exact date is unclear). A review of the appropriateness for continued residence and justification for the decision was not in writing and retained in the resident?s file prior to 5/30/24.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-120-A
Description:	Upon review of staff records the facility failed to verify that staff orientation and training occurred within the first seven working days of employment. Evidence: Orientation for staff #1(date of hire 5/30/23) was dated but not signed by the trainer. Staff #4 (date of hire 7/5/22) had no documentation of orientation retained in her record available for review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-B
Description:	Upon review of staff records the facility failed to ensure that all direct care staff attend at least 18 hours of training annually. Evidence: Staff #4 (date of hire 7/5/22) only has 2.5 hours of annual training documented.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records the facility failed to document prior to or at the time of admission all the information on the personal and social information form. Evidence: Resident #3 has no date of admission on the personal and social information form. Resident #4 has no date of admission on the personal and social information form. Resident #7 has no date of admission on the personal and social information form.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-380-B
Description:	Based on a review of resident records the facility failed to keep the personal and social information form current. Evidence: Resident #5 has a date of 3/25/22 on the personal and social information form but the resident was transferred to the memory care unit on 6/10/24 and the form was not updated to reflect this change.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to update the Uniform Assessment Instrument at least annually. Evidence: The only documented UAI retained in the file for resident #2 is dated 3/30/22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on a review of resident records the facility failed to update the Uniform Assessment Instrument at least annually. Evidence: Resident #1 has an UAI documented in their file dated 11/28/22 & 5/30/24. There is no documented UAI for 2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records the facility failed to review and update the resident individualized service plan at least once every 12 months. Evidence: ISPs retained in the file for resident #2 are dated 5/20/22 & 1/5/2024. There is no documented ISP for 2023. The only ISP in the resident file for resident #5 is dated 9/17/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Upon a review of staff and resident records the facility failed to ensure that the rights of residents in an assisted living facility were reviewed with each resident and staff annually. Evidence: There was no documentation retained in the resident record that rights were reviewed with residents #2,3&5 and staff #4 annually.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-E
Description:	Based on resident record reviews the facility failed to ensure that all resident records are current, retained at the facility and kept in a locked area. Evidence: Facility nursing staff were unable to find the resident record for resident #11.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-I
Description:	Based on a review of resident records the facility did not maintain a current picture or description of each resident for identification purposes. Evidence: There is no current picture in the resident record for residents #5 &9.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-B
Description:	Based on an inspection of the building the facility did not ensure that the building was free from foul odors. Evidence: During a tour of the facility a strong smell of urine was noted in bedroom #156.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-940-A
Description:	Upon review of required documents the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: The last fire inspection report conducted by the local fire official available for review was dated 8/11/22.
Plan of Correction:	Not available online. Contact Inspector for more information.