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. 18, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

An unannounced focused monitoring inspection was conducted on 11/18/22 to follow-up on a high-risk violation that was cited on 10/6/22. Medication administration and resident records were observed. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within five business days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. 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 #:	22VAC40-73-660-A
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 8:20 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 stated to have been removed and destroyed by a staff member no longer employed. ED has confirmed that medications have now been removed and destroyed. HWD and RMA staff have been counseled on the importance of storing and destroying medications properly and ED, HWD or Designee will monitor facility for medications improperly stored on ongoing basis.
Standard #:	22VAC40-73-680-D
Description:	Based on documentation, 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 October and November MARs (medication administration records) were reviewed during the inspection. Resident #1 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 #1's MAR included the following sliding scale for Novolog administration: 0U (BS= 0-150), 2U (BS= 151-200), 4U (BS= 201-250), 6U (BS= 251-300), 8U (BS= 301-350), 12U (BS= 351-400), Call MD (BS > 400) The MAR included the following administration of Novolog for Resident #1: 0U (BS= 158) on 11/8/22 (4:30 PM administration) 4U (BS= 267) on 11/16/22 (4:30 PM administration) Resident #1's blood sugar was documented as being 526 on 11/6/22 (4:30 PM administration), but no documentation of physician contact was included in the resident record. Resident #2's November MAR was reviewed during the inspection. Resident #2 has her blood sugar checked three times per day, and the MAR calls for her to receive Insulin units based on a sliding scale. Resident #2's MAR included the following sliding scale for insulin administration: 0U (BS < 150), 2U (BS= 151-200), 4U (BS= 201-250), 6U (BS= 251-300), 8U (301-350), 10U (351-400), Call MD for BS > 401 The MAR included the following administration of Insulin for Resident #2: 6U (BS= 233) on 11/1/22 (12:00 PM administration) 8U (BS= 265) on 11/1/22 (5:00 PM administration) 8U (BS= 260) on 11/2/22 (8:00 AM administration) 4U (BS= 151) on 11/2/22 (5:00 PM administration) 2U (BS= 222) on 11/4/22 (8:00 AM administration) 4U (BS= 175) on 11/4/22 (5:00 PM administration) 8U (BS= 241) on 11/5/22 (5:00 PM administration) 8U (BS= 227) on 11/6/22 (5:00 PM administration) 4U (BS= 265) on 11/8/22 (12:00 PM administration) 8U (BS= 287) on 11/8/22 (5:00 PM administration) 8U (BS= 250) on 11/9/22 (5:00 PM administration) 6U (BS= 234) on 11/10/22 (8:00 AM administration) 6U (BS= 234) on 11/10/22 (12:00 PM administration) 8U (BS= 275) on 11/10/22 (5:00 PM administration) 6U (BS= 182) on 11/11/22 (8:00 AM administration) 4U (BS= 145) on 11/11/22 (12:00 PM administration) 8U (BS= 169) on 11/11/22 (5:00 PM administration) 10U (BS= 283) on 11/12/22 (5:00 PM administration) 6U (BS= 230) on 11/13/22 (5:00 PM administration) 8U (BS= 171) on 11/14/22 (12:00 PM administration) 8U (BS= 281) on 11/14/22 (5:00 PM administration) 6U (BS=180) on 11/15/22 (8:00 AM administration) 8U (BS= 283) on 11/15/22 (12:00 PM administration) 8U (BS= 199) on 11/15/22 (5:00 PM administration) 4U (BS= 134) on 11/16/22 (8:00 AM administration) 4U (BS= 158) on 11/16/22 (12:00 PM administration) 8U (BS= 274) on 11/16/22 (5:00 PM administration) 8U (BS= 371) on 11/17/22 (5:00 PM administration)
Plan of Correction:	Medication administration for Resident #1 and Resident #2 were not administered as prescribed by the physician. HWD to discuss Resident #2's order with physician to ensure it is written in a clear and concise manner for the resident's medication needs. All RMA associates will be in-serviced on administering medications in accordance with physician orders and will include documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records. ED, HWD or designee will audit MAR weekly to ensure physician's orders are being followed for medication administration.
Standard #:	22VAC40-73-870-E
Description:	Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment are kept clean and in good repair. Evidence: Several ceiling access panels/covers were missing on the third floor. Closet doors were not installed and three light switch covers were missing in the room of Resident #3.
Plan of Correction:	Ceiling access panels in common hallway and light switch covers were missing and closet doors were not installed in Resident #3's room. The access panels in the common hallway had been removed during a maintenance repair and not replaced because a different size was needed. The correct sized access panels have been received and replaced. The closet doors found in Resident #3's room have been removed. The light switch covers had been removed during a repair and have been replaced. The DPO has been counseled on the importance of restoring items that are being maintained to their original or better condition and to ensure that they are in good repair. ED, DPO and/or designee will monitor facility on ongoing basis for areas in need of future repair.