Inspection Reports for
Morningside House of Leesburg, LLC

The inspection identified multiple violations related to outdated disclosure statements, incomplete annual health care oversight, medication management plan implementation failures, medication administration documentation issues, missing window screens, unsecured cleaning supplies, incomplete fire drill shift coverage, and delayed criminal record reports for staff.

Complaint related: Yes. The complaint was regarding Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance with standards or law.

The investigation did not substantiate the complaint allegations of non-compliance. However, a violation unrelated to the complaint was identified concerning the facility's failure to report an incident affecting resident safety to the regional licensing office within 24 hours.

The complaint was substantiated. Evidence included a self-reported incident of a missed medication dose, lack of notification to physician, family, or responsible parties, and failure to follow medication error reporting procedures.

The investigation found non-compliance with the medication management plan, specifically a missed dose of blood pressure medication due to pharmacy refill delays. Violations were issued based on resident record review, document review, and staff interviews confirming failure to implement the medication management plan.

Complaint related: Yes. Allegations involved resident care and related services, admission, retention, discharge of residents, and resident accommodations. The evidence gathered did not support the allegations of non-compliance.

The investigation did not substantiate the complaint allegations of non-compliance. However, a violation unrelated to the complaint was identified regarding failure to report a major incident to the regional licensing office within 24 hours.

The inspection identified multiple areas of non-compliance including lack of proper documentation for private duty personnel, absence of posted CPR/First Aid certification lists, missing resident acknowledgments of rights, failure to post weekly menus, incomplete certification on special diet oversight, expired items in the first aid kit, and insufficient emergency water supply.

The complaint was substantiated in part. Evidence included resident and staff interviews and record reviews. An incident involving a resident taking a photo and a staff member reacting aggressively was investigated. The facility failed to report suspected abuse to APS as required.

The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in resident care and related services, and resident accommodations and related provisions. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.

The complaint investigation was related to allegations of physical abuse and neglect. The evidence gathered did not support the allegations of non-compliance. Resident 1 reported multiple complaints about another resident's aggressive behavior and lack of staff intervention. Staff confirmed behavioral issues and interventions in place but noted no physical escalation or police involvement.

The investigation did not substantiate the allegations of abuse or neglect. However, violations unrelated to the complaint were identified, including failure to notify resident's contact person, incomplete staff training documentation, inadequate supervision of resident schedules and care, lack of written responses to resident council concerns, and failure to ensure residents are free from abuse and neglect.

The inspection found non-compliance with emergency preparedness standards, specifically regarding the emergency generator's capacity description and failure to notify families and the licensing office after a power outage emergency.

The inspection found non-compliance with several standards including staff certification in first aid, discrepancies between individualized service plans and uniform assessment instruments, improper use of physical restraints without physician orders, and failure to document Do Not Resuscitate (DNR) orders in service plans.

The complaint investigation was substantiated with violations issued related to personnel, staffing, resident care, medication administration, and discharge procedures.

The investigation found multiple violations including failure to provide discharge statements, delayed staff response to resident call bells, inadequate personal care documentation, unlicensed staff performing skilled nursing tasks, failure to prevent pressure ulcers, medication administration errors, and unsecured medication storage. Violations were substantiated and corrective plans were required.

The inspection was complaint-related, triggered by a complaint received on 12/9/22. Violations were substantiated as non-compliance with standards.

The inspection found non-compliance with applicable standards or laws, including failure to ensure resident agreements included descriptions of all accommodations, services, and care offered, and failure to ensure individualized service plans were signed by residents or their legal representatives.

The facility failed to ensure medication storage areas were locked, medications were not administered according to physician orders for two residents, and several furnishings and fixtures were not kept clean or in good repair.

The complaint was substantiated as valid based on a preponderance of evidence supporting allegations regarding staffing and supervision deficiencies.

The complaint was determined to be valid with violations found related to inadequate staffing levels and failure to maintain accurate staff work schedules. The facility failed to have sufficient staff during night shifts to meet resident care needs and did not maintain updated written work schedules reflecting staff coverage and substitutions.

The inspection identified multiple violations including failure to ensure staff first aid certification within 60 days, incomplete annual tuberculosis risk assessments for residents, delayed and unsigned individualized service plans, delayed staff response to call bells, unsecured medication storage, improper medication administration, missing DNR orders in records, incomplete emergency preparedness reviews, incomplete fire drill documentation, and missing criminal background checks for some staff.

The complaint was substantiated as valid based on a preponderance of evidence found during the inspection.

The inspection found a preponderance of evidence supporting the complaint, validating it. Violations included failure to ensure the service plan was filed in the resident record and failure to ensure medical procedures or treatments were provided and documented as ordered.

Complaint related: Yes. The complaint involved allegations in Resident Care and Related Services and Building and Grounds. The evidence supported non-compliance and violations were issued.

The investigation supported the allegations of non-compliance with standards or law, resulting in violations related to delayed staff response to resident call bells, incomplete physician medication orders, and failure to administer medications according to physician instructions.

The inspection found multiple violations including incomplete physical examination records, medication labeling and administration errors, improper storage of hazardous materials, maintenance issues with facility furnishings and equipment, and failure to post the most recent inspection findings.

The inspection found non-compliance with medication administration standards, specifically that several medications were not administered as prescribed due to unavailability or delays in delivery.