VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Morningside House of Leesburg
316 Harrison Street, SE
Leesburg, VA 20175
(703) 777-2777

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Nov. 4, 2021 , Nov. 23, 2021 and Nov. 29, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

A non-mandated complaint inspection was initiated on 11/4/21 and concluded on 12/3/21. A complaint was received by the department regarding allegations in the areas of: Resident Care and Related Services, and Building and Grounds. The administrator's designee was contacted by telephone to conduct the investigation. The licensing inspector conducted on-site observations at the facility on 11/4/21, 11/23/21, and 11/29/21. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances. Evidence: Resident #3?s May 2021 call bell reports were reviewed. The report indicates that Resident #3 pressed the call pendant 16 times during the month. The report indicated that there were 12 instances when staff members took 30 minutes to acknowledge the call bell, or the maximum alarm time was exceeded.
Plan of Correction:	Implemented a call bell escalation process to include call bells being sent to the HWD and ED's cell phones and emails if the call bell is active for 7 minutes. Daily call bell response report will be reviewed weekly by the HWD and ED to show effectiveness. An outlook calendar invite will be utilized to schedule this meeting. ED or designee to discuss results effectiveness at the quarterly QA meetings until compliance is established.
Standard #:	22VAC40-73-650-B
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that physician or other prescriber orders include how often a medication is to be given. Evidence: Resident #2's record included a prescription for elimite cream, dated 5/20/21. The order did not include how often the cream is to be applied.
Plan of Correction:	Resident #2 discharged on 8.19.21. HWD or designee will audit 100% of residents current physician orders for cream to ensure the order includes how often to apply. Health and Wellness Director or designee to discuss results of the random audits at the quarterly QA meetings until compliance is established.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with the physician?s or other prescriber'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 and June 2021 medication administration records (MARs) were reviewed during the inspection. Resident #1?s MAR calls for a blood pressure check three times per day. The MAR also calls for the staff to see Resident #1?s PRN order for Hydralazine, if Resident #1?s Systolic Blood Pressure (SBP) is greater than 160, or the resident?s Diastolic Blood Pressure (DBP) is greater than 100. The PRN Hydralazine order calls for Resident #1 to receive 25mg of Hydralazine three times a day as needed for SBP greater than 160 or DBP greater than 100. Resident #1?s DBP was 104 on 5/2/21 (6 AM), but there is no documentation of Hydralazine administration on that date. Resident #1?s SBP was 171 on 6/22/21 (6 AM), but there is no documentation of Hydralazine administration on that date. Resident #2?s MAR states that her Acetaminophen was not administered on 6/10/21 (2 PM administration), because the facility was ?waiting for pharmacy.? Resident #2?s MAR states that her Gabapentin was not administered on 6/21/21 (8 PM administration), because the facility was ?unable to provide medication.? Resident #3?s MAR states that the resident?s Eliquis, Levemir, and Melatonin were not administered on 6/11/21 (8 PM administration), as the medications were ?not available.?
Plan of Correction:	Resident #1 did not receive PRN medication on 5.02.21 and 6.22.21 at 6am as ordered. Resident #2 did not receive medication on 6.10.21 (2pm) and 6.21.21 (8pm) as ordered by physician. Resident #3 did not receive medication on 6.11.21 at 8pm as ordered by physician. RMA documented medication not available. RMA counseled by Health and Wellness Director. Health and Wellness Director or designee to educate current staff who administer medication on the Medication Policy to include medications being ordered in a timely manner and administered in accordance with physician orders. Health and Wellness Director or designee to conduct random monthly Medication Administration observations on current staff administering medication to verify that medications are being administered according to physician orders. Health and Wellness Director or designee to discuss results of the random audits at the quarterly QA meetings until compliance is established.