VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Morningside House of Fredericksburg
3020 Gordon W. Shelton Boulevard
Fredericksburg, VA 22401
(540) 370-8000

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: July 26, 2024

Complaint Related: No

Areas Reviewed:

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 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

Technical Assistance:

N/A

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/26/2024 8:30am ? 5:00pm 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: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed activities, breakfast meal, medication pass, building and grounds, Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-1120-B
Description:	Based on record review and staff interview, the facility failed to ensure at least 21 hours of scheduled activities were available to the residents. Evidence: 1. The July 2024 activity calendar did not document 21 hours of resident activities per week. 2. Staff 2 confirmed the number of hours was not posted on the activity calendar demonstrating at least 21 hours of activities were scheduled per week. 3. Photo evidence taken.
Plan of Correction:	Calendar demonstrated minimum of 21 hours requirement, but no ending time. Calendar was corrected for August 2024 calendar with the beginning and ending time for each activity daily. There shall be at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day. Director of Activity was in serviced and understands the expectations going forward. ED will monitor monthly to ensure compliance.
Standard #:	22VAC40-73-610-B
Description:	Based on observations, the facility failed to ensure menu substitutions or additions was recorded on the posted menu. Evidence: 1. During tour of the facility on 7/29/2024 the licensing staff observed the breakfast meal which included eggs, sausage, and toast with jelly. 2. The posted menu included eggs, sausage, French toast, and grits. 3. The posted menu was not updated with the toast with jelly substitution.
Plan of Correction:	Menu was corrected and updated 7/26/24, by Director of Dining Services. Any menu substitutions or additions shall be recorded on the posted menu by any Cook working or making the change immediately. All substitutions or additions shall be communicated to the Director after the substitution has been documented. The Director of Dining will be responsible for ensuring proper documentation is done prior to each meal.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and staff interview, the facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. LI observed a med pass, 7/26/2024, and reviewed the medication administration record (MAR). The LI observed prn medications listed on the MAR were missing from the medication cart. 2. Resident 1 had a physician order for routine treatment of moisture wicking fabric (order date 6/11/2024) and prn cream in the medication cart (order date 7/13/2024) were not available. 3. Resident 2 had a physician order for Aquaphor Ointment (order date 3/12/2024), and prn Loperamide 2mg capsule (order date 3/20/2024) were not available. 4. Resident 3 had a physician order for prn Acetaminophen 325 mg tablet (order date 3/19/2024), prn Loperamide 2mg capsule (order date 3/12/2024), prn Nystatin (order date 3/19/2024), prn Miralax (order date 3/12/2024), and prn Ureacin ?20 cream (order date 3/12/2024) were not available. 5. Staff 3 acknowledged that the medications were not available.
Plan of Correction:	Full audit conducted from signed physician orders versus carts. All PRN medications were re-ordered and available for all residents in the community on 8/1/24. Medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Daily RMA will audit and reorder any medications that are 10 days or less from running out. This will be reported daily to Wellness Nurse. Wellness nurses will document and track all medications until they arrive in the community. ECP our electronic mar system has been equipped with medication re-order dial. In the event medication is destroyed or expired all medications can be easily ordered by the nurse or RMA with a push of a button. DON will be responsible for compliance and monthly auditing.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interview, the facility failed to ensure the first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. The LI observed the first aid kit, located in the Wellness Office, did not include a blanket, tweezers, hand sanitizer, scissors, and triangle bandage. 2. Staff 4 acknowledged the first aid kit was missing items.
Plan of Correction:	All items within the First aid kit were replenished 8/1/24- First aid kit shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. A complete first aid kit shall be on hand at the facility, located in a designated place that is easily accessible to staff but not to residents. All first aid kits will be signed off monthly by RMA on a ledger listing all items that should be included, date, and signature. ED on the last day of each month will finalize for completion.
Standard #:	22VAC40-73-980-H
Description:	Based on observation and staff interview the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water and that at least 48 hours of the supply must be on site at any given time. Evidence: 1. During tour of the facility on 7/26/2024 the LI observed 48 ? 8oz. bottles. 2. Staff 1 acknowledged that 48 hours of emergency water was not in stock.
Plan of Correction:	48-hour emergency water supply was replenished 8/1/24 by Director of Dinning Services. The community will ensure the availability of a 96-hour supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility's rotating stock may be used. Stock will be rotated by Director of Dining at the end of each month and signed off and submitted to ED.