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. 19, 2021

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 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:

A renewal inspection was initiated on 10/19/21 and concluded on 10/22/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 44. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, activity calendar, and other facility documentation to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/22/21. An exit interview was conducted with the administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that the physical examination, completed Within the 30 days preceding admission, includes all of the required information. Evidence: Resident #1?s physical examination form, dated 8/24/21, includes a list of the resident?s allergies. The examination form did not include Resident #1?s reactions to the allergens. Resident #3's physical examination form, dated 6/2/21, states that the resident is allergic to sulfa. The examination form did not include information about Resident #3's reaction to the allergen.
Plan of Correction:	Addendums were added to Resident #1 and #3 history and physical forms to include reactions to allergens. Current H&P form was revised to include reactions to allergens. HWD or designee to audit 100% of all new move-ins to ensure compliance in reactions to allergens are included. HWD or designee will report results at the quarterly QA meeting until compliance is established
Standard #:	22VAC40-73-680-B
Description:	Based on observation, the facility failed to ensure that medications remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: The first floor medication cart was observed during the inspection. An unlabeled insulin pen was observed in the medication cart. No information was attached to the pen to indicate which resident was to receive the medication or directions for its use.
Plan of Correction:	Immediate correction was taken at the time of the survey. Unlabeled insulin pen was identified as belonging to resident in apartment 101. Insulin pen was labeled accordingly on 10.22.2021. Health and Wellness Director or designee will conduct monthly random audits of first floor med cart to ensure compliance in medication labeling. Results of the audits will be reported at the quarterly QA meetings until compliance is established.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, 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 September MAR was observed during the inspection. Resident #1?s PRN Acetaminophen order, dated 8/25/21, calls for the resident to receive two 325mg tablets every four hours as needed for pain or temperature. The MAR documents that Resident #1 was administered PRN Acetaminophen on 9/7/21 at 1:35 PM and 3:26 PM. Four hours did not elapse between the two administrations of Acetaminophen.
Plan of Correction:	Resident #1 had PRN order to receive two Acetaminophen 325mg tablets every four hours as needed for pain or temperature. On 09.07.2021 resident was administered PRN Acetaminophen at 1:35 PM and 3:26 PM. Four hours did not elapse between the two administrations of Acetaminophen. RMA's will receive remediation/refresher training on PRN order frequency. Health and Wellness Director or designee to conduct random audits of residents Medication Administration Records to ensure compliance in administration times of PRN medications. Health and Wellness Director or designee to discuss results of the random audits at the quarterly QA meetings until compliance is established.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure that the medication administration record (MAR) includes all of the required information. Evidence: Administration information was not present for Resident #1?s Amiodarone from 9/2/21 through 9/4/21. Resident #1?s record included an order, dated 9/15/21, that calls for the resident?s blood pressure medications to be held, if the resident?s Systolic Blood Pressure (SBP) is less than 100. Blood pressure readings were not present for the administration of Resident #1?s Amlodipine Besylate and Lisinopril from 9/16/21 through 9/27/21. No information was documented on the MAR for the application of Resident #1?s Diclofenac patch on 9/8/21 (9 AM). No information was documented on the MAR for the administration of Resident #1?s Ertapenem on 9/25/21. No information was documented on the MAR for the administration of Resident #1?s Gabapentin on 9/1/21 (5:30 AM administration), 9/3/21 (1:30 PM administration), and 9/4/21 (1:30 PM administration). No information was documented on the MAR for the administration of Resident #2?s Atorvastatin or Carvedilol on 9/27/21 (8 PM administration).
Plan of Correction:	RMA's were reeducated on needed documentation for medication administration. HWD or designee to conduct random audits on medication administration records for appropriate documentation for medication administration. HWD or designee will report results at the quarterly QA meeting until compliance is established.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: A spray can of "Belt Dressing" was found unlocked and unattended in third floor stairwell. The warning on the can's label states that the contents are extremely flammable and harmful or fatal if swallowed.
Plan of Correction:	Immediate correction was taken at the time of the survey. Spray can of "Belt Dressing" found in third floor stairwell was removed and placed in a secure area. Maintenance Director to conduct random rounds of third floor stairwell to ensure all cleaning supplies and other hazardous materials are in locked areas. Maintenance Director or designee to report results of random audits at the quarterly QA meeting.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, are kept clean and in good repair and condition. Evidence: Ceiling vent covers were observed to be missing for several vents on the hallway of the second floor. Electrical wiring was also observed hanging from the ceiling, near a missing ceiling vent cover.
Plan of Correction:	Immediate correction was taken at the time of the survey. Ceiling vents on the second floor were covered on 10.26.2021. Electrical wiring was covered by new vent coverings. Maintenance Director to conduct random rounds on the second floor hallway to ensure all vents are covered and no electrical wiring is exposed. Maintenance Director or designee to report results of random audits at the quarterly QA meeting.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and interview, the facility failed to ensure that the findings of the most recent inspection of the facility were posted. Evidence: The licensing inspector was unable to locate the findings of the most recent inspection posted at the facility. Facility staff confirmed that the inspection findings were not posted.
Plan of Correction:	Immediate correction was taken at the time of the survey. ED posted finding of most recent inspection at concierge desk. Concierge was reeducated on need to keep most recent inspection results posted at the concierge desk. ED or designee will conduct weekly audits to ensure compliance in most recent survey results being posted. ED or designee to report findings at the Quarterly QA meeting until compliance is established.