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: Feb. 17, 2023 , March 17, 2023 and April 4, 2023

Complaint Related: Yes

Areas Reviewed:

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 BUILDINGS AND GROUNDS 63.2 FACILITIES AND PROGRAMS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Unannounced complaint inspection visits were conducted on 2/17/23, 3/17/23, and 4/4/23 in response to complaints received by the licensing office on 1/17/23 and 1/25/23 regarding: Personnel; Staffing and Supervision; Admission, Retention and Discharge of Residents; Resident Care and Related Services; Building and Grounds. Medication administration, staff documentation, resident records, and facility grounds were observed. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint, but identified during the course of the investigation can also 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-430-H-1
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that a discharge statement is provided to the resident (or their legal representative), at the time of discharge. Evidence: Resident #6's discharge record was observed during the inspection. No documentation was provided, during the inspection, to indicate that Resident #6 was provided with a discharge statement at the time of discharge.
Plan of Correction:	Resident #6 was discharged from the facility and was not provided a discharge statement. Resident #6 received various correspondence regarding discharge via email but was not provided a formal discharge statement after exiting the facility. A discharge statement was emailed to the resident on the date of the inspection. ED will ensure all residents discharging from the facility moving forward will be provided with a discharge statement.
Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances. Evidence: Call bell reports for January were reviewed during the inspection. Resident # 3's call bell report indicated that there were 155 occasions when it took staff 30 minutes to respond to the resident's call bell (out of 230 call alarms). Resident #4's call bell report indicated that there were 215 occasions when it took staff 30 minutes to respond to the resident's call bell (out of 409 call alarms). Resident #5's call bell report indicated that there were 57 occasions when it took staff 30 minutes to respond to the resident's call bell (out of 111 call alarms).
Plan of Correction:	Residents #3, #4 and #5 did not receive aprompt response by staff to resident needs. Upon review of the documents provided, Resident #3, Resident #4 and Resident #5 exceeded maximum response time for call bells on 34, 58 and 24 unique occasions, respectively, during the time period reviewed. None of the requests resulted in staff finding an ?emergency? when the call was answered. On 4.12.23, facility has implemented a new call bell system that provides additional tools for identifying resident call bells and promotes better response times. ED and HWD have provided in-service to staff on importance of answering call bells in a timely manner in conjunction with the training of the new call bell system. ED and HWD will monitor through email notification when a call bell goes unanswered for ten minutes and meet to review the response times on a weekly basis for the next 60 days to ensure improvements are made.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that personal assistance and care is provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: Bathing - at least twice a week, but more often if needed or desired. Evidence: The facility's February shower logs (2/1/23 ? 2/16/23) were observed during the inspection. Resident #3's ISP, dated 11/16/22, states that he needs staff assistance for bathing. Resident #3's only documented shower, during the review period, was completed on 2/15/23. The shower log documented that Resident #3 refused showers on two occasions (2/1/23 and 2/3/23), during the review period. Resident #5's ISP, dated 1/10/23, states that she needs staff assistance for bathing. Resident #5's only documented shower, during the review period, was completed on 2/7/23.
Plan of Correction:	Residents are scheduled to receive two or more showers per week and a log is kept by staff members to record whether the shower was given or refused by the resident. Staff members failed to document the outcome of the scheduled showers for Resident #3 and Resident #5. Staff members have been in serviced on the importance of documenting outcomes of resident care provided. HWD or designee will review shower logs weekly to ensure accurate documentation is kept for resident showers.
Standard #:	22VAC40-73-470-B
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that a resident?s need for skilled nursing treatment is met by a licensed nurse. Evidence: Staff #1 documented changing Resident #2's dressing in December 2022. Staff #1 is a registered medication aide. No training records or health care license, was provided during the inspection, to indicate that Staff #1 had the appropriate training or licensure to complete dressing changes. Resident #2 was noted to have stage 1 pressure sores on her heels and redness on her buttocks, upon her admission in November 2022. On 12/12/22, Resident #2's progress notes state that the resident?s coccyx has a stage 2 wound that is increasing in size. The notes, completed by a home health provider, states that the dressing should be changed when soiled. Progress notes indicated that Staff #1 changed Resident #2?s dressing in December 2022. No training records or nursing licensure was provided, during the inspection, to document that Staff #1 had the appropriate training or licensure to perform wound care/dressing changes.
Plan of Correction:	Staff #1 holds a current First Aide certification, is a Registered Medication Aide and is studying to be an LPN at Standard Healthcare College of Nursing. Staff #1 has completed coursework in Foundations of Nursing Skills/Concepts; Geriatric Nursing Skills and Concepts; Sterile Dressing Change Training and has completed over 50 hours of direct patient care in long term care setting. Staff #1 was providing dressing changes and wound care based on regular assessments and direction from skilled nursing licensed professionals on how to care for the resident between assessments. Facility was not aware that RMA's were qualified to change some butnot all wound dressings. Facility will ensure moving forward that only a LPN/RN will provide wound care to any resident with an advanced staged wound.
Standard #:	22VAC40-73-470-C
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that services are provided to prevent clinically avoidable complications, including: pressure ulcer development or worsening of an ulcer. Evidence: Resident #2's record contains a progress note, dated 12/12/22, that states that the resident's stage 2 wound is increasing in size and that the resident must be repositioned every two hours. Resident #2's ISP, dated 11/10/22, states that she needs maximum assistance for transfers and a Hoyer lift to be transferred into a wheelchair. Resident #2's ISP did not include documentation that she needed to be turned and repositioned every two hours. Resident #2's MAR included documentation that the resident was turned and repositioned, every two hours, beginning 12/28/22. No information was provided, during the inspection, to document that Resident #2 was turned and repositioned (every two hours) from 12/12/22 until 12/28/22.
Plan of Correction:	Resident #2 was admitted to the facility on 11.16.23 and an ISP was created on 11.10.23 in accordance with ALF Regulations. Following the addition of documentation to the MAR that the resident should be turned and repositioned every two hours, a revision to the ISP of record was not made. HWD has been inserviced on the importance of ensuring continuity throughout all documentation when a change in care services is implemented. Regional HWD, ED or designee will conduct a random audit monthly of resident e-charts to ensure documentation is accurate and consistent with standards of practice.
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that no medications, dietary supplement or treatment is started, changed, or discontinued without a valid order from a physician or other prescriber. Evidence: Resident #1's record contained orders, dated 1/4/23, that called for the resident's Metformin, Ferrous Sulfate, and Vitamin C to be discontinued. The orders also called for Resident #1's Rosuvastatin to be changed from 40mg to 20mg. Resident #1's medication administration record (MAR) indicates that his Metformin, Ferrous Sulfate, and Vitamin C were not discontinued until February 2023. Resident #1's Rosuvastatin was not changed from 40mg to 20mg, until February 2023. Resident #1's record contained an order, dated 1/4/23, for Vitron-C to be administered daily. No administrations of Vitron-C were included on Resident #1's MAR. Resident #2 was admitted to the facility on 11/17/22. Resident #2's admission medication list included Eucerin topical cream, and it was to be administered to a rash on the resident's back. Resident #2's November treatment administration record (TAR) did not include documentation of Eucerin administration/application.
Plan of Correction:	Medication administration for Resident #1 and Resident #2 were not administered as prescribed by the physician and consistent with the standards of practice. Policy and standards of practice were reviewed with HWD and changes to MAR/TAR based on inspection findings were implemented immediately. HWD performed audit of MAR and resident orders to ensure medications matched physician orders and any medications that should be discontinued were correctly reflected in both the MAR/TAR and the resident chart. Regional HWD, ED or designee to perform random audit monthly on resident files and MAR/TAR to ensure quality control.
Standard #:	22VAC40-73-660-A-1
Complaint related:	No
Description:	Based on observation and documentation, the facility failed to ensure that a medicine cabinet is used for the storage of medications and that the storage area is locked. Evidence: At approximately 8:30 AM on 2/17/23, the first-floor medication cart was observed to be unlocked and unattended.
Plan of Correction:	Medication should be kept in a medicine cabinet and this area should be locked when not in use or unattended. All RMA associates have been in-serviced on the importance of ensuring this standard of practice is maintained for the integrity of the contents and the safety of all residents and staff. ED, HWD or designee will do random spot checks of medication carts to ensure this practice is maintained.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that medications are administered within one hour of the facility?s standard dosing schedule,Based on documentation, the facility failed to ensure that medications are administered within one hour of the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: Resident #1's January MAR was reviewed, during the inspection. Resident #1's Digoxin was scheduled to be administered by 9 AM daily. Resident #1's Digoxin was administered at 10 AM on 1/26/23 and at 10:25 AM on 1/29/23. Resident #1's Gabapentin (administered 3 times per day) was scheduled to be given by 10 AM, 3 PM, and 9 PM. Resident #1's Gabapentin was administered at: 4:03 PM on 1/20/23, 10:46 PM on 1/22/23, and 10:12 on 1/24/23. Resident #1's Montelukast Sodium was scheduled to be given by 8 PM daily. Resident #1's Montelukast Sodium was administered at: 10:17 PM on 1/21/23, 10:47 PM on 1/22/23, 10:14 PM on 1/24/23, and 9:39 PM on 1/28/23. Resident #1?s Quetiapine was scheduled to be given by 5 PM daily. Resident #1's Quetiapine was administered at: 6:29 PM on 1/21/23, 6:18 PM on 1/22/23, and 8:02 PM on 1/27/23. Resident #6's MAR indicates that she had evening administrations of Eliquis and Metoprolol Succinate that are scheduled to be given by 9:00 PM. Resident #6?s Eliquis and Metoprolol were administered after 10:20 PM on 1/21/23 and 1/22/23.
Plan of Correction:	Medication administration for Resident #1 and Resident #6, was not administered timely as prescribed by the physician and consistent with the standards of practice. All RMA associates have been in-serviced on the importance of administering medication timely in accordance with standards of practice of medication administration, administering medications in accordance with physician orders and will include proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on documentation, 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 medication aide curriculum approved by the Virginia Board of Nursing. Evidence: The morning medication administration, for Resident #3, was observed during the inspection. Resident #3's insulin order calls for him to receive the medication before meals. Resident #3 was observed receiving insulin, after he began eating breakfast.
Plan of Correction:	Medication administration for Resident #3, wasnot administered as prescribed by the physician and consistent with the standards of practice. All RMA associates have been in-serviced on the importance of standards of practice of medication administration, administering medication in accordance with physician orders and including proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records. ED, HWD or designee will conduct audit weekly of insulin administration to ensure medication is administered per physician orders.