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. 5, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of Inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/5/23 (9:00 AM ? 6:00 PM). 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of interviews conducted with resident: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration, activities An exit meeting was held. 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. 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 #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment. Evidence: No documentation was provided, during the inspection, to confirm that Staff #1 (hired 6/12/23) or Staff #2 (hired 6/6/23) had current certification in first aid.
Plan of Correction:	Staff #1 and Staff #2 did not have current First Aid Certification. Staff #1 had First Aid Certification that was expired and had already taken the class for both CPR and First Aid prior to inspection but not within the 60 days of new hire. Staff #1 is not compliant. Staff #2 had current CPR and BLS/AED certification provided at hire but did not have First Aid. Staff #2 will obtain First Aid Certification to meet requirements within 30 days. ED or Designee will audit personnel records to ensure all clinical staff members are current with CPR and First Aid certifications and monitor monthly moving forward to ensure compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on documentation, the facility failed to ensure that the comprehensive individualized service plan (ISP) is based upon the uniform assessment instrument (UAI). Evidence: Resident #1?s UAI, dated 9/1/23, states that he needs no assistance for eating. Resident #1?s ISP, dated 9/5/23, states that assistance is required for the resident to eat meals. Resident #5?s UAI, dated 7/26/23, states that he needs no assistance for dressing. Resident #5?s ISP, dated 8/10/23, states that he requires monitoring, verbal prompts and cues for dressing.
Plan of Correction:	Resident #1 and Resident #5 UAIs did not match the current ISPs. Current ISPs were created for each resident and the corresponding UAIs were not updated to reflect the current service plan. HWD or Designee will audit resident UAIs and ISPs to ensure they match and make any necessary corrections. HWD will ensure both the UAI and ISP are reviewed for any future care changes and updated accordingly. ED or Designee will spot audit monthly to ensure compliance.
Standard #:	22VAC40-73-710-B
Description:	Based on observation and documentation, the facility failed to ensure that physical restraints are used as a medical/orthopedic restraint for support, according to a physician's written order and with the written consent of the resident or his legal representative or (ii) in an emergency situation after less intrusive interventions have proven insufficient to prevent imminent threat of death or serious physical injury to the resident or others. Evidence: Bed rails were observed on the bed of Resident #4. Resident #4?s record contained a physical examination form, dated 7/26/23, indicating that she has a cognitive impairment and that she is non-ambulatory. Resident #4?s ISP, dated 7/31/23, does not include information about her use of the bed rail. No physician?s orders were observed, in Resident #4?s record, to indicate the rails were necessary as a medical/orthopedic restraint for support.
Plan of Correction:	Resident #4 does have a bed rail in place per the family's request for support not restraint. Facility will obtain documentation from the resident's legal representative as well as an order from the physician to document the necessity of the rails currently in place for support. ED or Designee will ensure any future use of bed rails for support will be documented and signed off by legal representative and physician.
Standard #:	22VAC40-73-720-A
Description:	Based on documentation, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation are included in the individualized service plan. Evidence: Resident #1?s record contained a DNR, dated 12/11/20. Resident #1?s DNR was not documented on his ISP, dated 9/5/23. Resident #2?s record contained a DNR, dated 4/18/23. Resident #2?s DNR was not documented on his ISP, dated 9/6/23.
Plan of Correction:	DNR orders were not listed on Resident #1 and #2 individualized service plans. The Facility maintains records for all residents for DNR status and advises of status to staff in the medication management system and the resident chart but did not indicate the DNR status on the individualized service plan per the regulation. Facility has audited all resident charts and noted on each individualized service plan the DNR status. ED or Designee will ensure the DNR status is on all future ISP's created.