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Lansdowne Heights, LLC
19520 Sandridge Way
Leesburg, VA 20176
(703) 936-7300

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Aug. 4, 2021 and Aug. 11, 2021

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 BUILDING AND GROUNDS
22VAC40-73 EMERGENCY PREPAREDNESS
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Article 1
Subjectivity
32.1 Reported by persons other than physicians
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:
A renewal inspection was initiated on 8/4/2021 and concluded on 8/11/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 30. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, activities calendar, menu, staff work schedule, fire drill reports, and the annual health and fire inspection reports submitted by the facility to ensure documentation was complete Criminal Background Checks of all staff hired since the previous mandated inspection conducted on 8/11/2020 were reviewed. The inspector conducted the on-site portion of the inspection on 8/6/2021. An exit interview was conducted with the Director of Personal Care and the Business Office Manager on 8/11/2021 where findings were reviewed and an opportunity was given for questions, as well as for providing any information which was not available during the inspection.

Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days.

Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s).

Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:
Standard #: 22VAC40-73-640-A
Description: Based upon a review of records and interview, the facility failed to implement the written plan for medication management to ensure the effective use of MARS (Medication Administration Records) for documentation.

Evidence: Documentation obtained from the facility confirmed that Resident #1 was out of the building during the time that 12:30pm, 13:00 (1pm), and 14:00 (2pm) medications were to be administered on 7/11/2021 and 7/13/2021. The Medication Administration Record (MAR) did not indicate that on 7/11/2021 and 7/13/2021 Resident #1 was out of the facility and not administered regularly scheduled medications at 12:30pm, 13:00 (1pm), and 14:00 (2pm).

Progress notes for 7/11/2021 and 7/13/2021 stated that Resident #2 did receive the regularly scheduled Ensure Supplement. The MAR did not record that on 7/11/2021 and 7/13/2021 at 1300 hours (1pm) Resident #2 was administered the Ensure Supplement.

Plan of Correction: Staff members that pass medications (RN, LPN, and RMA) will be trained by 9/30/2021 on Medication Administration Record (MAR) documentation for residents that are not available for scheduled medication administration. Director of Personal Care, Care Manager, or Administrator will measure progress and compliance by completing Electronic Medication Administration Record (EMAR) reviews regularly.

Standard #: 22VAC40-73-680-H
Description: Based upon a review of documentation and interview the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.

Evidence:
1. Resident #3 has an physician?s order, dated 07/07/2021, to receive Novolog 100unit/mL 2 units injected subcutaneously before meals. The dosage times listed on the Medication Administration Record are 0700 am; 11:30 am, and 16:30 pm (4:30pm). According to the Location of Administration Report, that is part of the MARS, the dosage time and time of administration for the following dates listed below, would indicate that the medication was either not administered on time or that documentation was entered late.

7/9/2021 11:30am dosage administered at 14:29

7/9/2021 16:30 dosage administered at 18:03

7/11/2021 16:30 dosage administered at 19:08

7/12/2021 11:30 am dosage administered at 13:17

7/12/2021 16:30 dosage administered at 21:33

7/13/2021 11:30 am dosage administered at 19:26

7/13/2021 16:30 dosage administered at 19:26

7/14/2021 11:30 am dosage administered at 15:16

7/15/2021 16:30 dosage administered at 18:10

7/16/2021 16:30 dosage administered at 20:31

7/18/2021 16:30 dosage administered at 20:27

7/19/2021 16:30 dosage administered at 18:31

7/20/2021 11:30 am dosage administered at 14:22

7/21/2021 11:30 am dosage administered at 14:55

7/21/2021 16:30 dosage administered at 21:22

7/22/2021 11:30 am dosage administered at 14::35

7/25/2021 7:00 am dosage administered at 10:33 am
7/25/2021 16:30 dosage administered at 18:36

7/29/2021 16:30 dosage administered at 18:13

7/30/2021 16:30 dosage administered at 18:42

7/31/2021 16:30 dosage administered at 20:39


Interview with staff #3 revealed that this staff spoke with each staff responsible for administering the medication on the dates listed, and all staff reported that the medication was administered on time but that the documentation was done at a later time. The administered time listed on the Location of Administration Report, according to staff #3 is actually the time the staff documented the administration of the medication.

Evidence:

Plan of Correction: Staff members that pass medications (RN, LPN, RMA) will be trained by 9/30/2021 on how to complete Medication Administration Record (MAR) documentation for medication and supplement administration at the time of administration and how to note if medication was not administered within the timeframe prescribed. Director of Personal Care, Care Manager, or Administrator will measure progress and compliance by completing Electronic Medication Record (EMAR) reviews regularly.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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