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Public Google reviewers rate Morningside House of Leesburg, LLC highly. Reviewers highlight: compassionate and long-tenured staff, excellent food and dining options. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Morningside House of Leesburg is highly regarded by families for its exceptionally warm, family-like atmosphere and a stable, long-tenured staff that demonstrates genuine compassion. Reviewers frequently praise the high quality of food, the cleanliness of the facility, and the vibrant social activities available to residents. While the vast majority of feedback is overwhelmingly positive, one reviewer provided a neutral 3-star rating without specific details.
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Key Review Excerpts
“My mom has been at Morningside House of Leesburg for almost 3 years. She is very happy there and the staff are very attentive and truly care about her. The minute you walk in you feel welcomed!”
“Unlike many "institutional" senior care homes, Morningside is warm and inviting and the most of the staff have been there over 15 years or more. That should say something!”
“I just moved my 94 year old mother-in law into Morningside House a few days ago and I am so impressed and pleased with the place & the wonderful staff!”
Source: VA State Licensing Agency
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/04/2026 10:45 AM to 11:30 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/02/2026 regarding allegations in the area(s) of: 1. Admission, Retention, and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident record. Additional Comments/Discussion: Resident was unavailable for interview at time of inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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. The evidence gathered during the investigation did not support the allegation non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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. Should you have any questions, please contact Amanda ?AJ? Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/04/2026 9:35 AM to 10:45 AM 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (Selective) Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication Cart Audit ? 1st, 2nd, and 3rd Floor Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 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). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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.Should you have any questions, please contact Amanda ?AJ? Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Based on resident record review and staff interview, the facility failed to ensure all medications administrations to residents were documented on the medication administration record ( MAR
Based on resident record review and staff interview, the facility failed to ensure medications ordered for [as needed] PRN
Based on facility document review and interview, resident record review, direct observation and staff interview, the facility failed to ensure a written plan for medication management was kept current, implemented, and addressed procedures for administering medication including required components. Evidence: 1. The Medication Management Plan was submitted via email by Staff 2 on 02/02/2026 and approved by the department on 02/06/2026. 2. Resident 1?s Medication Administration Record ( MAR
Based on resident record review and staff interview, the facility failed to ensure medication was administered in accordance with the physician or other prescribers? instructions and consistent with the standards of practice approved by the Virginia Board of Nursing. Evidence: 1. Resident 1?s chart contained an order for Vitamin C 250 MG Gummy that states to chew and swallow two gummies by mouth every day for supplement. 2. Resident 1?s Medication Administration Record ( MAR
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/04/2026 11:30 AM to 1:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/31/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident Records Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 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). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Should you have any questions, please contact Amanda ?AJ? Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Based on resident record review and staff interview, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident was reported to the regional licensing office within 24 hours. Evidence: 1. Resident 1?s record contains discharge paperwork from the emergency department dated 01/04/2026, that indicates Resident 1 was seen for a fall resulting in a head injury. 2. Resident 1?s record contains discharge paperwork from the emergency department dated 01/31/2026, that indicates that Resident 1 was seen for a fall resulting in a head injury, traumatic hematoma, shoulder injury, and multiple abrasions/lacerations. 3. In an interview with two LI?s on 03/04/2026, Staff 1 confirmed that the reports for Resident 1 were not submitted within 24 hours.
Based on resident record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities included attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: 1. Resident 1?s UAI
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan ( ISP
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/17/2025 8:30 AM to 4:06 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 7 Observations by licensing inspector: Activities, Meals, and Medication Pass/Medication cart audits on all three floors. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. 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. 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 Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident records and staff interviews, the facility failed to ensure all residents were included annually in the health care oversight. Evidence: 1. The Record of On-Site Health Care Oversight was reviewed for the last year. The form dated 07/18/2025 contained a list of 13 residents. The form dated 01/24/2025 contained a list of 11 residents. 2. In an interview with the LI on 10/22/2025, Staff 1 stated that a random selection of residents was chosen during each oversight period. Staff 1 confirmed that not all residents were included annually in the healthcare oversight.
Based on staff record review and staff interview, the facility failed to ensure that the criminal record report was obtained on or prior to the 30th day of employment. Evidence: 1. The following staff records contained documentation that the Criminal Record Report was completed more than 30 days after hiring: a. Staff 12, hired on 01/01/2025, Criminal Record Report obtained on 03/10/2025 b. Staff 13, hired on 01/27/2025, Criminal Record Report obtained on 03/10/2025 c. Staff 14, hired on 01/30/2025, Criminal Record Report obtained on 03/10/2025 2. In an interview with the LI on 10/17/2025, Staff 1 confirmed the criminal record reports for Staff 12, Staff 13, and Staff 14 were not obtained on or prior to the 30th day of employment.
Based on resident records and staff interview, the facility failed to ensure that the medication management plan was implemented. Evidence: 1. While on site at the facility, a pack of Gabapentin was observed with two visually different pills taped into the back of the bubble pack. 2. Staff 1 provided a copy of the medication management plan to the LI on 10/17/2025. 3. Page 09 of the medication management plan states the following, ?Controlled medications are destroyed by medications by disposing in a contained labeled specifically for medication distribution?? The medication management plan later states that a report sheet is used to document the destruction of controlled substances, which is then signed by multiple leadership positions, and faxed to drug control. 4. In an interview with the LI on 10/17/2025, Staff 1 confirmed that nothing had been reported regarding the two pills being removed, and additional pills being taped into the pack. 5. In an interview with the LI on 10/17/2025, Staff 1 confirmed the medication plan was not followed.
Based on direct observation and staff interview, the facility failed to ensure cleaning supplies and hazardous materials were stored in a locked area. Evidence: 1. During a tour of the facility, the LI observed that the employee lounge door was propped open and accessible to residents. Inside the lounge, both the cleaning supply closet and laundry room doors were also propped open. Multiple cleaning products were observed including laundry detergent, room sprays, wipes, and spray bottles. No staff were present in the employee lounge, closet, or laundry room. 2. In an interview with the LI on 10/17/2025, Staff 1 confirmed that the cleaning supplies were not stored in a locked area. 3. Photo evidence obtained.
Based on resident records and staff interview, the facility failed to ensure the disclosure statement was on the form developed by the department. Evidence: 1. The following resident records contained disclosure statements on outdated disclosure statement forms: a. Resident 3, admitted 07/25/2025 b. Resident 4, admitted 03/06/2025 c. Resident 6, admitted 02/14/2025 d. Resident 7, admitted 10/06/2025 2. In an interview with the LI on 10/17/2025, Staff 1 confirmed that Resident 3, Resident 4, Resident 6, and Resident 7?s records contained outdated disclosure forms.
Based on facility document review and staff interview, the facility failed to ensure the drills were conducted on each shift in a quarter. Evidence: 1. The Record of Required Fire and Emergency Evacuation Drills stated that the following drills were all conducted at 2:00 PM: a. 05/29/2025 b. 06/26/2025 c. 07/31/2025 d. 08/28/2025 e. 10/01/2025 2. In an interview with the LI on 10/17/2025, Staff 1 confirmed that the drills were not being conducted on different shifts throughout each quarter.
Based on direct observation and staff interview, the facility failed to ensure that all operable windows were screened. Evidence: 1. During a tour of the facility, the LI observed the following windows without screens: a. 3rd floor hallway near room 324 b. 3rd floor lobby c. 1st floor, stairs to dining area d. Various unidentified windows on the outside of the building 2. In an interview with the LI on 10/17/2025, Staff 1 confirmed that the windows did not have screens. 3. Photo evidence obtained.
Based on resident records and staff interview, the facility failed to ensure that medication shall remain in the pharmacy issued container with the prescription label or direction label attached until administered to the resident. Evidence: 1. During a medication cart audit on the 1st floor with Staff 3, the LI observed a pill pack containing Resident 9?s prescribed Gabapentin. The medication pack, containing 31 pills, had two pill slots that had been popped out, replaced with two visually different pills, and then taped shut. 2. The Narcotic Count sheet provided to the LI indicated that two pills were removed in error, initialed by an unidentified staff member. 3. On 10/17/2025, Staff 1 and Staff 11 could not determine who or why the pills had been removed from the pharmacy issued container and replaced. 4. In a follow-up email to the LI on 10/20/2025, Staff 1 stated that Staff 11 initialed the correction solely looking at the total number of pills and not realizing that the two pills had been replaced and taped over. 5. Photo evidence obtained.
Based on resident records and staff interviews, the facility failed to ensure that medication administration was documented on the medication administration record ( MAR
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 03/10/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2025 9:15 AM to 11:00 AM 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Resident Room Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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. 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 Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on staff interview, the facility failed to ensure that any incident that has negatively affected or that threatens the life, health, safety or welfare of any resident as reported to the regional licensing office within 24 hours. Evidence: 1. On 03/10/2025, a complaint was received by the regional licensing office regarding an incident that occurred between Staff 6 and Resident 1. 2. In an interview with the LI on 05/15/2025, Staff 1 stated that Resident 2 had concerns about the attitude of Staff 1 affecting the care of Resident 1. Staff 1 confirmed that an incident report was not submitted regarding the incident between Staff 6 and Resident 1.
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 01/09/2025 regarding allegations in the area(s) of: medication administration. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/03/2025 11:00 AM to 12:30 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint 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. 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 Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review, facility document review, and staff interview, the facility failed to ensure that the medication management plan was implemented. Evidence: 1. On 01/09/2025, Staff 1 notified the LI via email of a self-reported incident. The email stated, ?We have a resident, [Resident 1], who missed an evening and morning dose of BP medication due to waiting on pharmacy for refill.? 2. On 02/03/2025, Staff 2 provided the LI with a copy of the facility?s medication management plan. The medication management plan states the following: a. ?Medication errors will be immediately reported to the DHW [Director of Health and Wellness] or ED [Executive Director] via phone. Resident?s physician and family member/responsible party shall be notified as soon as possible. Action shall be taken as directed by a physician, pharmacist, or poison control center. Actions taken will be documented by a nurse or medication aide. The ED or DHW will complete appropriate follow-up.? 3. Resident 1?s, admitted 12/09/2024, scheduled medications for December 2024 contain the following prescriber order: Eliquis 5 MG Tablet. The directions state ?Take one tablet by mouth every 12 hours for [Diagnosis].? 4. Resident 1?s Medication Administration Record ( MAR
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 11/07/2024 regarding allegations in the area(s) of: resident care & related services, admission, retention, and discharge of residents, and resident accommodations and related provisions. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/08/2024 9:15 AM to 12:55 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: resident room. Additional Comments/Discussion: This inspection was a joint inspection with Adult Protective Services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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. 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 Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review, staff interview, and resident interview, the facility failed to ensure a report was given to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Resident 1?s, admitted 07/12/2023, record contains a progress note written by Staff 1 that states the following: a. On 11/01/2024, ?Resident notified writer that [Resident 1] was ?assaulted? by [Resident 2]. Interviewed staff members [Initials of Staff 2 and 3] in dining. [Resident 2] did shake table but did not come in contact with resident. Resident 1 contacted 911 to file report on [Resident 2]; [Resident 2] interviewed with [Staff 1] and information taken. No action taken by LCPD.? 2. In an interview with the LI on 11/08/2024, Resident 1 confirmed that Resident 2 shook the table and was yelling in the resident?s face. Resident 1 stated that they reported to both Staff 1 and the police. 3. In an interview with the LI on 11/08/2024, both Staff 2 and 3 confirmed that Resident 2 yelled at and shook the table near Resident 1. Staff 2 stated that they overheard Resident 1 say they were going to police as they were leaving the dining area. 4. An initial report of the incident was not sent to the licensing office. 5. In an interview with the LI on 11/08/2024, Staff 1 acknowledged that a report should have been sent to the licensing office.
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/10/2024 9:40 AM to 5:05 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: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: meals, activities, medication pass. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. 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. 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 Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure that written acknowledgment of the review of the rights and responsibilities was filed in the resident?s record. Evidence: 1. Resident 1?s, admitted 02/09/2023, record did not contain an annual acknowledgment of the Resident Rights and Responsibilities. 2. Resident 2?s, admitted 03/04/2023, record did not contain an annual acknowledgment of the Resident Rights and Responsibilities. 3. Resident 5?s, admitted 05/13/2023, record did not contain an annual acknowledgment of the Resident Rights and Responsibilities. 4. In an interview with the LI on 10/10/2024, Staff 1 stated that the Resident Rights are discussed during resident council and emailed to all legal reps, as well as shared in resident mailboxes. Staff 1 confirmed that there was not acknowledgement of receipt in the resident records.
Based on facility document review and staff interview, the facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services, the facility will maintain proper documentation including written information on the type and frequency of services listed, required tuberculosis (TB) reports, orientation and training regarding the facility?s policies and procedures, and documentation of resident care. Evidence: 1. In an interview with the LI on 10/10/2024, Staff 1 stated that Resident 1 has a private duty aide through an agency. Staff 1 confirmed the facility does not have a file including a written copy of the type and frequency of services that will be provided, a tuberculosis screening, record of facility orientation and training, or documentation of resident care on either private duty companion
Based on direct observation and staff interview, the facility failed to ensure menus for meals and snacks for the current week were posted in an area conspicuous to residents. Evidence: 1. During a tour of the facility including all floors and common areas, the LI observed a daily menu that stated, ?assorted snacks always available.? 2. In an interview with the LI on 10/10/2024, Staff 1 confirmed that there not a snack menu or weekly menu posted elsewhere in the facility. 3. Photo evidence obtained.
Based on facility document review and staff interview, the facility failed to ensure that certification that the requirements of this subsection were met was included in the oversight of special diets. Evidence: 1. Staff 1 provided the special diets oversight for 04/30/2024, 01/30/2024, and 10/31/2023. 2. The dietician oversight for all three (3) dates did not include certification that requirements of the standards were reviewed and included in the oversight. 3. In an interview with the LI, Staff 1 acknowledged that the certification statement was not included on the special diet oversight.
Based on direct observation and staff interview, the facility failed to ensure 48 hours of the 96 hour emergency water supply was on site at any given time. Evidence: 1. The census for 10/10/2024 was 67. 2. During a tour of the kitchen storage and staff areas, the LI observed approximately 15 gallons of emergency water. 3. In an interview with the LI on 10/10/2024, Staff 1 confirmed there was no additional water on site. 4. Photo evidence obtained.
Based on direct observation and staff interview, the facility failed to ensure items in the first aid kit with expiration dates did not have dates that have already passed. Evidence: 1. During a tour of the wellness room and offices, the LI observed a first aid kit. 2. The first aid kit contained antiseptic ointment that expired 09/2023 and First Aid Wound Saline Wash that expired 06/25/2024. 3. In an interview with the LI, Staff 3 confirmed the first aid kit contained expired items. 4. Photo evidence obtained.
Based on direct observation and staff interview, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, was posted in the facility so that the information is always readily available to all staff. Evidence: 1. During the onsite tour of the building to include all floors, common areas, the nurse?s station and the staff break area, the LI did not observe a posted list of all staff certified in CPR/First Aid. 2. In an interview with the LI on 10/10/2024, Staff 1 stated that they were unsure if they needed to post the list as all direct care staff are certified.
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