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: July 9, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/17/2024 regarding allegations in the area(s) of physical abuse and neglect. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/09/2024: 1:10 PM to 4:00 PM. 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-B
Complaint related:	Yes
Description:	Based on staff interview, the facility failed to ensure the resident's contact person or legal representative was notified when a report is made relating to the resident. Evidence: 1. An APS report was referred on 06/14/2024 regarding the care of Resident 1. 2. Staff 1 and 2 were unsure if a report had been submitted to Resident 1?s contact person when notified of the report. 3. Staff 3 confirmed via phone interview that Resident 1?s contact person was not notified because the resident is their own representative and has requested that nobody contact Resident 1?s relations. 4. No documentation was provided to verify this information.
Plan of Correction:	Reporting resident is own POA and facility inadvertently mistook this to mean that the emergency contact did not need to be contacted. Facility will contact resident contact person or emergency contact for any future reports made to state or local agencies regarding resident welfare.
Standard #:	22VAC40-73-210-G
Complaint related:	No
Description:	Based on staff record review and staff interview, the facility failed to ensure documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training were kept by the facility. Evidence: 1. Staff 4?s record contains a document titled ?Employee Annual Training- Mandatory? that is signed on 09/20/2023 and states ?I have been in serviced in the training topics below I have received handouts for each topic so that I may refer to the topic if I need to at a later date and completed the testing packet associated with each.? 2. The document lists the following topics as in-serviced: Abuse and Neglect, basic CPR, Basic First Aid, Basic Food Safety, Bloodborne Pathogens, Fire Safety, Disaster Preparation/Planning, Infection Control and Precautions, and Resident Rights. 3. The annual training log has ?post test? questionnaires attached for each topic. 4. Staff 5?s record contains the same ?Employee Annual Training ? Mandatory? document and was signed on 09/24/2024. 5. The ?Employee Annual Training ? Mandatory? document t does not include the type of training received, the number of training hours, or the date of each training. 6. Staff 2 confirmed that this is the only documentation provided for annual training, and that it does not contain specific information about the training including the type of training, number of training hours, or the date of each training.
Plan of Correction:	All Staff receive annual training compliance hours in topics required by State regulations. The facility did not total the number of hours received on the packet provided to staff. The facility has revised the packet to include the number of hours credited for the continuing education provided.
Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities including attention to specialized needs was provided. Evidence: 1. Resident 1 `s Uniform Assessment Instrument, completed 07/12/2023, lists her behavior as ?appropriate? with no notes of inappropriate behavior. 2. Staff 1, 2, and 3 all confirmed that Resident 1 has behavioral concerns with refusal of care, intervening in care of other residents, and being verbally aggressive with staff. 3. Staff 1 and 2 stated that Resident 1 had been discharged from the facility at one time and was previously re-admitted on 07/12/2023. 4. Staff 1 and 2 stated that these concerns were present in both her previous and current admissions in the facility. 5. Staff 1 and 2 confirmed that this is not documented in the resident record through progress notes, incident reports, or on the most recent Individualized Service Plan (ISP) and the interventions currently in place are using a preferred caregiver whenever possible.
Plan of Correction:	Facility did not indicate on UAI, ISP or progress notes that resident #1 exhibited behavioral issues and additional care intervention was in place when caring for this resident. Facility has added these notations to resident #1?s UAI, ISP and progress notes.
Standard #:	22VAC40-73-830-E
Complaint related:	No
Description:	Based on facility document review and staff interview, the facility shall provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns. Evidence: 1. Staff 2 provided the resident council notes to review regarding resident concerns. 2. In discussion of the resident council notes, Staff 2 confirmed the facility does not provide a written response to residents prior to council. 3. Staff 2 stated the current method is reviewing the response during the resident council meeting.
Plan of Correction:	Facility holds Resident Council every month for resident feedback. Facility provided verbal responses to resident council concerns but did not provide the response in writing. Facility will provide residents with written response to each Resident Council meeting at the next scheduled Resident Council meeting the following month.
Standard #:	63.2-1808-A-10
Complaint related:	Yes
Description:	Based on resident interview and staff interview, the facility failed to ensure that each resident is free from mental, emotional, physical, sexual, and economic abuse or exploitation; is free from forced isolation, threats or other degrading or demeaning acts against him; and his known needs are not neglected or ignored by personnel of the facility. Evidence: 1. Resident 1 stated that they had made 4 or 5 complaints to the facility regarding Resident 2 bothering her. 2. Resident 1 stated that this resident has been both verbally and physically aggressive. 3. Resident 1 stated that they have told Staff 3; however, they don?t do anything about it. Resident 1 has said that Staff 3 will ?sidestep? around the issue and that the facility (both staff and residents) are a ?great big club against me.? 4. Resident 1 documented phone calls to Leesburg Police on February 01st, 2024 and March 28th, 2024, regarding the incidents that have occurred with Resident 2. 5. Resident 1 stated that most incidents happen in the club room during bingo which has resulted in not participating in activities and/or having to sit alone during meals. 6. Staff 1, 2, and 3 verified that there has been a history of altercations between Resident 1 and 2; however, it has not escalated physically. 7. Staff 1, 2, and 3 stated that police have not been on site regarding these incident(s). 8. Staff 2 and 3 said that the current intervention in place is that Resident 2 has agreed to stay away from Resident 1. 9. When asked about attending activities, Staff 2 verified that Resident 1 has stopped coming to activities and stated that she understands why the Resident 1 doesn?t come because the other residents in the facility ?don?t like her.? 10. Staff 2 and 3 stated that Resident 1?s decision to avoid activities was supported by the staff to help avoid altercations between Resident 1 and 2.
Plan of Correction:	Resident #1 has known behavioral issues and difficulty interacting with residents and staff in the community. ED has met with Resident #1 as well as multiple residents and staff members to facilitate a community approach that addresses the concerns while meeting the needs of all residents in the community. Resident #1 has been encouraged to attend group activities and has received guidance and assistance in setting up activities led by Resident #1 with residents they are comfortable with; Resident #1 will also be provided opportunities outside of group activities to ensure they don?t feel isolated and are contributing to the community. ED has assisted Resident #1 in identifying residents in the dining room with like interests to sit with at mealtime.