VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon a review of records, the facility failed to implement the medication management plan to ensure medication orders have been accurately transcribed to medication administration records (MARS) within 24 hours of receipt of a new order or change in an order. Evidence: According to the physician?s order written on 7/12/2022 for Resident #2, the resident was to receive Donepezil 5mg, 2 tablets by mouth daily at bedtime. The order was entered on the July MARS as follows: Donepezil Give 5mg by mouth at bedtime.
Plan of Correction:	Lansdowne Heights reviewed medication administration records for resident number two and corrected error for sited resident on July 20, 2022. Going forward, Lansdowne Heights will fax new orders to pharmacy once received by prescribing physician. Pharmacy will enter orders into electronic medical record once received. Lansdowne Heights will verify original orders match the medication administration recorded within 24 hours. Responsible Position: Director of Personal Care, Licensed Practical Nurse
Standard #:	22VAC40-73-680-C
Description:	Based upon a review of records, the facility failed to ensure that medication shall be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule. Evidence: According to the Medication Administration Records (MARS), Resident #3 is to receive Toujeo SoloStar Solution Pen Injector 300units/ML daily at approximately 9:00am. The Location of Administration Report documents the following time of administration of the medication: 1.On 7/5/2022 the medication was administered at approximately 10:45 am 2. On 7/9/2022 the medication was administered at approximately 14:09 (2:09 pm) 3. On 7/10/2022 the medication was administered at approximately 10:38am 4. On 7/14/2022 the medication was administered at approximately 10:27 am 5. On 7/17/2022, the medication was administered at approximately 10:54 am 6. On 7/18/2022 the medication was administered at approximately 11:36 am 7. On 7/21/2022 the medication was administered at approximately 10:45 am. According to the MARS Resident #2 is to receive a Trulicity Solution pen injector 0.75mg/0.5ML at approximately 9:00am on Saturdays. According to the Location of Administration Records, the medication was administered at approximately 11:29 am on 7/9/2022 and at approximately 10:55 am on 7/16/2022.
Plan of Correction:	Lansdowne Heights and Primary Care Physicians will review medication administration times for all residents. Adjustments will be made on medications that can be moved to less busier times to stagger medication pass so residents receive medications during an appropriate window. This will be completed periodically as new residents move-in and at care plan review. Education will be conducted to all appropriate staff on timely administration. Responsible Position: Director of Personal Care, Licensed Practical Nurse, Medication Aide.
Standard #:	22VAC40-73-680-H
Description:	Based upon a review of records, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration records (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: No initials were entered on the July 2022 Medication Administration Record (MAR) on 7/8/2022 and 7/13/2022 to document that Resident #4 received the prescribed Lorazepam 0.5mg 1 tablet at approximately 9:00am. The Controlled Drug Record documents that the Lorazepam 0.5mg was administered to Resident #4 at approximately 9am on 7/8/2022 and 7/13/2022.
Plan of Correction:	Lansdowne Heights will verify that all medication documentation is properly recorded on Medication Administration Record and controlled substance log prior to the end of each shift. Education will be conducted to all appropriate staff on Medical Administration Record/Controlled Substance log documentation periodically. Responsible Position: Director of Personal Care, Licensed Practical Nurse, Medication Aide