VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Morningside at Skipwith (West End)
3000 Skipwith Road
Richmond, VA 23294
(804) 270-3990 (320)

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: April 25, 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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

Annual Risk Assessments- 250.D.2c Each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form.

Comments:

An unannounced monitoring inspection was conducted at the facility on 4/25/2022. The Director of Resident Care was on-site and reported 75 residents in care. The inspector reviewed five staff and five resident records, the menu, the activity schedule, fire and health inspections, dietitian report, staff schedule, required postings. health care oversight, medication storage and administration, observed a medication pass and inspected the building for compliance. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations are documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on a review of five resident files, there was no documentation to support that a written approval was obtained prior to placing one resident in the safe, secure environment. Evidence: Resident # 1 was admitted to the safe, secure environment on 2/21/22, the written approval form was dated 3/15/23.
Plan of Correction:	ED and or DON will ensure all proper documents are signed upon admission with correct date, according to state regulations.
Standard #:	22VAC40-73-120-B
Description:	Based on a review of five resident files, one staff did not receive orientation and training as required by the regulations on or within 7 days of employment. Evidence: The date of hire for staff # 1 is documented as 3/8/22. Documentation of training and orientation that included all of the required elements was not found during a review of the file for staff # 1 on 4/24/22 with facility staff.
Plan of Correction:	ED, BOM, and or DON will ensure all new hires have completed proper paperwork, orientation and training according to state regulations.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of five staff files, one staff did not have current certification in adult first aid. Evidence: There was no documentation to support current certification in adult first aid for staff # 5. The date of hire for staff # 5 is documented as 12/21/2021.
Plan of Correction:	ED, BOM, and or DON will ensure all new hires have completed proper training and it is documented in their files according to state regulations, Unable to correct staff # 5 as she is no longer employed.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of five resident files, the individualized service plan for one resident was not updated as needed for a significant change in the resident's condition. Evidence: The date of admission for resident # 4 is 4/21/21. The physical examination for resident # 4 dated 4/17/21 documents a history of alcohol abuse. A physician's order for resident # 4 dated 1/26/22 states "limit of 6 ounces of alcohol per day, no alcohol after 6 pm". The resident's file documents falls related to the use of alcohol. The resident's individualized service plan has not been updated to address this identified need.
Plan of Correction:	DON will ensure all ISP's are up to date and correctly show all pertinent information to ensure proper care is giving