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 28, 2023 and May 2, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

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: LI entered the facility at 10:00am on 4/28/2023 and exited at 12:00pm. LI entered the facility at 2:45 pm on 5/2/2023 and exited at 5:00 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 4/27/2023 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 59 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: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based upon a review of records and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the health, safety, or welfare of any resident. Evidence: 1. On 4/28/2023 LI reviewed progress notes for Resident #1. The progress note dated 3/5/2023 documented that Resident #1 had returned to the facility from the hospital at approximately 5:00am on 3/5/2023 and the progress note indicated that Resident #1 was treated at the hospital for ?fall and contusion, bruises on multiple part of the body, no head injury, resident alert and oriented to self, no changes in her confused state.? 2. On 5/9/2023 LI asked the administrator if anyone from the facility had submitted to the LI a report regarding the incident that led to Resident #1 being sent out to the hospital on 3/4/2023. On 5/9/2023 the administrator responded that he was not ?100% sure? that anyone submitted a report regarding Resident #1 being sent to the hospital on 3/4/2023.
Plan of Correction:	The administrator or designee will e-mail the licensing inspector when a resident is sent to the hospital and verify if report is warranted.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. On 5/2/2023, LI found the following information documented in sampled residents records: a. The physician?s order for Diltiazem CD for Resident #1, written on 8/11/2021, evidenced the following instructions for administration: give 1 capsule by mouth one time a day for hypertension. b. The April 20223 Medication Administration Record (MAR) indicated that Diltiazem was not administered to Resident #1 at approximately 9 am on the following dates: 4/6/2023, 4/8/2023, and 4/18/2023. c. Progress notes written on 4/6/2023 at approximately 9:28 and 4/18/2023 at approximately 9:12 am documented that Resident #1 was not administered Diltiazem for hypertension because hypertension ?was not indicated at this time.? Progress note written on 4/8/2023 at approximately 11:02 am documented that Resident #1?s Diltiazem was ?not given bp low
Plan of Correction:	The facility will re-educate the Med Techs and nurses regarding following physician?s orders.