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: April 6, 2023 and April 10, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

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: LI entered the facility at 11:25 am on 4/6/2023 and exited at 2:05 pm on 4/6/2023. LI entered the facility at 1:10 pm on 4/10/2023 and exited at 2:55 pm on 4/10/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self- report was received by VDSS Division of Licensing on 3/28/2023 and 4/10/2023 regarding allegations in the area(s) of resident care and related services, buildings and grounds, and additional requirements for facilities that care for adults with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 58 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 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed camera footage of incidents that occurred on 3/24/2023 and 4/10/2023. LI observed resident?s rooms, including windows and mechanisms in place to prevent the window from opening wide enough for a resident to crawl through. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based upon a review of records and interviews, the facility failed to ensure that when hospice care is provided, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: According to an interview LI conducted with the administrator on 4/10/2023, Resident #3 was admitted into hospice services on 2/9/2023. The Individualized Service Plan (ISP) that was reviewed by LI on 4/10/2023 for Resident #3 did not include hospice services.
Plan of Correction:	The community will review and update all individualized service plans for residents that are receiving hospice care by 4/28/23. Facility and Hospice will review bi-weekly that the established plan of care is added to the residents Individualized Service Plan