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: Oct. 6, 2022

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 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

Comments:

An unannounced renewal inspection was conducted on 10/6/22 (8:35 AM ? 6:45 PM). At the time of entrance, 43 residents were in care. Meals, medication administration, and an activity were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member receives certification in first aid within 60 days of employment. Evidence: The record for Staff #4, hired 5/24/22, was reviewed during the inspection. Staff #4?s record contained documentation of CPR certification, but it did not contain documentation of first aid certification. No documentation was provided, during the inspection to indicate that Staff #4 received first aid certification within 60 days of his employment.
Plan of Correction:	Direct Care staff are required to have First Aid certification within 60 days of employment. Staff #4 was hired on 5/24/22 and presented documentation of CPR, AED and BLS training. This training does not include the required certification of First Aid. Staff #4 will complete the required First Aid training by 11.1.22. ED or designee will audit staff records on a monthly basis to ensure First Aid certification is obtained and maintained per state regulations.
Standard #:	22VAC40-73-320-B
Description:	Based on documentation, the facility failed to ensure that a risk assessment for tuberculosis is completed annually for each resident. Evidence: The tuberculosis risk assessments for Residents #3 (September 2021), #5 (June 2021), and #6 (July 2021) were more than a year old, at the time of the inspection.
Plan of Correction:	Residents #3, #5, and #6 did not obtain a new tuberculosis assessment on an annual basis as required. HWD or Designee will audit all resident records to ensure all residents have an annual tuberculosis assessment. HWD or designee will maintain a list of the residents and their due date for their annual TB screening and review the list monthly to ensure completion of those assessments due. The Executive Director or designee will ensure compliance with quarterly QA meetings with the management team.
Standard #:	22VAC40-73-450-C
Description:	Based on documentation, the facility failed to ensure that the comprehensive individualized service plan (ISP) is completed within 30 days after admission. Evidence: Resident #2 was admitted to the facility in March 2022, but the first ISP included in her record was dated 9/29/22. Resident #7 was admitted to the facility in April 2022, but the first ISP included in her record was dated 9/29/22. No additional documentation was provided during the inspection.
Plan of Correction:	Resident #2 and Resident #7's ISPs were not completed and made as part of the resident's records within 30 days of admission. Prior to the inspection, all resident records were audited to ensure an ISP was included for all residents and documentation was placed in the record with the current date by the HWD. HWD or Designee will audit resident records on a monthly basis to ensure proper documentation is completed in a timely manner. The ED or designee will ensure compliance with quarterly QA meetings with the management team.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that each ISP is signed by the resident or their legal representative. Evidence: The ISPs for Residents #2 (9/29/22), #3 (11/6/21), #6 (1/27/22), #7 (9/29/22), and #8 (4/5/22) were not signed by the resident nor their legal representative.
Plan of Correction:	Resident #2, #3, #6, #7 and #8's ISPs were not signed by the resident or their legal representative. Facility will have these documents signed by the resident or legal representative by 11.1.2022. HWD or designee will audit all resident records to ensure resident ISPs are signed by the appropriate resident representative.
Standard #:	22VAC40-73-460-B
Description:	Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances. Evidence: Call bell reports for August and September were reviewed during the inspection. Resident #4?s call bell report indicated that the maximum response time (30 minutes) was reached on 15 occasions for the resident?s call bell. Resident #7?s call bell report indicated that the maximum response time (30 minutes) was reached on 31 occasions for the resident?s call bell.
Plan of Correction:	Residents #4 and #7 did not receive a prompt response by staff to resident needs. Resident #4 and Resident #7 received maximum response time for call bells on 15 and 31 occasions, respectively, during the time period reviewed. During this time period, Resident #4 used the call bell system 280 times and Resident #7 used the call bell system 743 times for requests; none of the requests resulted in staff finding an "emergency" when the call was answered. HWD will provide an in-service to staff on importance of answering call bells in a timely manner. ED and HWD will monitor through email notification when a call bell goes unanswered for ten minutes and meet to review the response times on a weekly basis for the next 60 days to ensure improvements are made.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area is locked. Evidence: Amoxicillin, probiotic pills, and ointments were observed to be unlocked and unattended in the closet of the therapy room shortly after 8:40 AM.
Plan of Correction:	Medications were found in an unlocked area of the therapy room. The area where the unlocked medications were observed was an area that was previously but not currently used for medication storage. The observed medications were discontinued medications for residents no longer residing in the facility and were destroyed. HWD and RMA staff have been in-serviced on the importance of storing and destroying medications properly.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication. Evidence: Antacid tablets, Bayer, and Mucus D-M were observed in the room of Resident #2. Resident #2?s UAI, dated 9/26/22, states that the resident needs her medication administered/monitored by professional nursing staff.
Plan of Correction:	Medications were observed in Resident #2's room. The medications observed in the resident's room were over-the-counter medications brought into the facility without facility consent by the resident's family. The medications were removed from the resident's room and the resident and family were notified and counseled regarding policy of having non-physician ordered medications available for the resident's use. An inspection of all resident rooms was conducted and any medications observed for non-self-administering residents were removed. HWD and RMA staff members have been in-serviced on the importance of monitoring rooms for unauthorized medications.
Standard #:	22VAC40-73-680-D
Description:	Based on documentation and observation, the facility failed to ensure that medications are administered in accordance with physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Medication administration for Resident #1 was observed during the inspection. Resident #1?s record contained a PRN order for Gas Relief 80mg, dated 3/10/22, to be given after meals and at bedtime. During the inspection, Resident #1 was given PRN Gas Relief before she ate lunch. Medication administration for Resident #2 was observed during the inspection. After Resident #2 was given a pill cup containing her medication, she dropped a Furosemide tablet on the floor. The medication aide retrieved the Furosemide tablet and gave it back to the Resident to take. Resident #9?s September MAR (medication administration record) was reviewed during the inspection. Resident #9 has his blood sugar (BS) checked three times per day, and the MAR calls for him to receive Novolog units (U) based on a sliding scale. Resident #9?s MAR included the following sliding scale for insulin administration: 2U (BS= 151-200), 4U (BS= 201-250), 6U (BS= 251-300), 8U (BS= 301-350), 12U (BS= 351-400) The MAR included the following administration of Novolog for Resident #9: 0U (BS= 155) on 9/12/22 at 4:30 PM 0U (BS= 154) on 9/15/22 at 4:30 PM 0U (BS= 168) on 9/23/22 at 4:30 PM 0U (BS= 157) on 9/29/22 at 4:30 PM
Plan of Correction:	Medication administration for Resident #1, Resident #2, and Resident #9 were not administered as prescribed by the physician and consistent with the standards of practice. All RMA associates will be in-serviced on standards of practice of medication administration, administering medications in accordance with physician orders and will include proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records.
Standard #:	22VAC40-73-720-A
Description:	Based on documentation, the facility failed to ensure that each Do Not Resuscitate (DNR) Order is included in the resident?s ISP. Evidence: Resident #3?s record contained a DNR order, dated 5/24/22. Resident #3?s ISP, dated 11/6/21, was not updated to include the DNR order.
Plan of Correction:	Resident #3's ISP did not contain the change to information regarding the residents' DNR status. HWD or designee has audited all resident records to ensure the current ISP reflects the most recent DNR status for all residents.
Standard #:	22VAC40-73-950-E
Description:	Based on documentation, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff. Evidence: Staff records were reviewed during the inspection. The most recent review on the emergency preparedness and response plan was completed in November 2021.
Plan of Correction:	Staff members should review the emergency preparedness plan bi-annually. Staff members have been assigned to review emergency preparedness and response plan training documents upon date of hire and annually. Facility had already assigned all staff members with emergency preparedness and response plan training documents dated 9.16.22 based on an incorrect interpretation of the requirement. ED or designee will ensure all staff members complete the training document on a bi-annual basis.
Standard #:	22VAC40-73-970-E
Description:	Based on record review, the facility failed to ensure that emergency evacuation drill records include all of the required information. Evidence: The facility?s fire drills were reviewed during the inspection. The fire drill reporting forms (7/19/22, 8/25/22, 9/14/22) did not include: the time of drill, method used for notification of the drill, the time it took to complete the drill, and weather conditions.
Plan of Correction:	Emergency drills did not include all required details of the drills. The emergency evaluation drills were facilitated monthly as required but did not include documentation of the time of the drill, method of notification, length of time to complete and weather conditions. Facility acknowledges the requirement for missing information and will ensure proper documentation using VA DSS form 032-05-0059-03-ENG for future emergency drills.
Standard #:	22VAC40-90-40-B
Description:	Based on documentation, the facility failed to obtain a criminal history record report within 30 days of each employee?s hire date. Evidence: The records for Staff #5 (hired 2/27/22) and Staff #6 (hired 5/1/22) did not contain a criminal history record report within 30 days of their hire dates.
Plan of Correction:	Criminal background checks were not obtained for Staff #5 and Staff #6. Staff #5 and Staff #6 were re-hired to the facility following a brief period of non-employment at the facility but longer than 30 days. The facility failed to obtain new criminal history reports on these staff members at the time of re-hire. New criminal history reports were obtained on the day of inspection and no criminal history was on record. ED or designee will ensure all staff members, including re-hired staff members, will have a criminal history report reviewed prior to employment.
Standard #:	22VAC40-90-40-C
Description:	Based on documentation, the facility failed to ensure that any individual is ineligible for employment if their criminal history record report contains barrier crime convictions. Evidence: The criminal history record reports for new employees were observed during the inspection. The criminal history record report for Staff #7, hired 3/17/22, contained felony convictions for barrier crimes (18.2-57 and 18.2-58).
Plan of Correction:	Staff #7 criminal history contains a barrier crime. Staff #7 was hired and the criminal history record report was reviewed prior to employment. The record contained a conviction for a barrier crime dated 24 years prior and the regulation for the statute of past history was misinterpreted by the facility. Based on the clarification, the staff member has been released from employment by the facility.