VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Morningside of Charlottesville
491 Crestwood Drive
Charlottesville, VA 22903
(434) 971-8889

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Feb. 19, 2020

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced 60 day inspection was conducted at the facility by two licensing representatives on 2/19/2020 from approximately 12 noon to 3:30 pm. The facility reported 83 residents in care. Licensing staff reviewed resident and staff files, required file and program documentation, elevator/health/fire inspection reports, observed building maintenance and communicated with residents and staff. All new personnel records were reviewed since the last inspection for criminal history record reports and all were in compliance. Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard, 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). See violation notice for non-compliance

Violations:

Standard #:	22VAC40-73-720-A
Description:	Based on a review of resident files on 2/19/2020, the do not resuscitate order for resident # was not accurately documented on the resident's individualized service plan. Evidence: The individualized service plan for resident # 6 included a goal to withhold cardiopulmonary resuscitation (CPR ) in the event of cardiac or respiratory arrest. Next to the goal was stamped "Full Code". Full Code is defined as using all resuscitation procedures in the event of cardiac or respiratory arrest.
Plan of Correction:	22VAC40-73-(6) 720-A Steps to correct the noncompliance with the standards (1.) Resident #6 ISP was amended at the time of the inspection 2/19/2020 and the issue was addressed prior to the licensing inspector completing the survey. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: The facility Director of Resident Care and/or authorized designee shall review the 72hr ISP?s of all residents admitted in the last 30 days and all new admissions once per month for a period of 3 months to ensure future compliance with this standard and code status is clearly understandable. (Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: The facility Director of Resident Care and/or authorized designee shall review the 72hr ISP?s of all residents admitted in the last 30 days and all new admissions once per month for a period of 3 months to ensure future compliance with this standard and code status is clearly understandable.