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: June 2, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted on 6/2/22 (1:30 PM ? 4:20 PM) in response to a complaint received by the licensing office on 5/5/22 regarding: Resident Care and Related Services. A preponderance of evidence was found to support the allegation and the complaint is considered to be "valid." 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 10 calendar 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. Thank you for your cooperation and if you have any questions, please call (703) 431-4247 or contact me via email at M.Massenberg@dss.virginia.gov 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

Violations:

Standard #:	22VAC40-73-450-G
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that the service plan is filed in the resident record. Evidence: The record for Resident #1, admitted 3/31/22, was observed during the inspection. Resident #1?s individualized service plan (ISP) was not in the resident record, at the time of the inspection.
Plan of Correction:	Resident #1 was admitted on 3.31.22. The ISP was not in the resident record. The ISP was filed in the resident record on 6.3.22. HWD or designee will audit 100% of resident records for ISP. Random monthly audit of resident records will be conducted to ensure updated ISPs in resident record and discussed at quarterly QA meetings.
Standard #:	22VAC40-73-680-E
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that medical procedures or treatments are provided and documented. Evidence: Resident #2?s record contained an order, dated 2/2/22, that called for the resident to be turned in bed every two hours. Resident #2?s treatment administration record (TAR) was observed during the inspection. There was no documentation of Resident #2 being turned on the following dates/times in May 2022: 5/4/22 (10 PM), 5/9/22 (10PM), 5/11/22 (8AM), 5/14/22 (10PM), 5/23/22 (10PM), 5/24/22 (Noon), 5/25/22 (10PM), 5/26/22 (Noon), 5/26/22 (10PM), and 5/28/22 (10PM).
Plan of Correction:	Resident #2 physician order for resident to be turned every two hours. The TAR indicated missing documentation of resident being turned. RMA's counseled by HWD 6.23.22 to educate current staff on medication administration/treatments and proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records. A daily audit of the TAR will be conducted for 14 days then a random monthly audit will be conducted and results presented at quarterly QA meeting.