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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: June 5, 2023 and July 5, 2023

Complaint Related: No

Areas Reviewed:
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 12:50 pm on 6/5/2023 and exited at 3:10 pm. LI entered the facility at 10:17 am on 7/5/2023 and exited at 12:20pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 5/30/2023 regarding allegations in the area(s) of administration and administrative services and resident care and related services.

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:
Additional Comments/Discussion:

An exit meeting will be conducted to review the inspection findings.

The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:
Standard #: 22VAC40-73-70-A
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 threatens the life, health, safety, or welfare of any resident.
Evidence:
1. On 5/30/2023 LI received a self-reported incident from Staff #1 documenting that in February 2023, the facility was made aware that medications for Resident #1 had been discontinued in November 2022 and ?they should not have been.?
2. During interview held on 6/12/2023, collateral contact #1 revealed to LI that on 2/16/2023 she reviewed the medication report for Resident #1 and asked the director of personal care ?where did mom?s medications go.?

Plan of Correction: ? The administrator or designee will e-mail the Licensing Inspector when an incident occurs that threatens the resident?s health, safety, or welfare within 24 hours and verify if a report is warranted.

? The facility will provide an in-service to LPNs about how to return expired, discontinued, or unused medication to the pharmacy. Community will retain a copy of the medication return receipt in the resident electronic medication record.

Standard #: 22VAC40-73-650-A
Description: Based upon a review of records, the facility failed to ensure that no medications shall be discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over the counter, and sample medications.
Evidence:
1.On 6/25/2023 LI inspected the medication administration records (MARS) for Resident #1. The MARS evidenced that the following medications were stopped:
? Amlodipine Besylate 5mg was discontinued on 11/17/2022.
? Furosemide 20mg was discontinued on 11/17/2022.
? Hiprex Tablet 1gm was discontinued on 11/18/2022.
? Omeprazole Tablet 20mg was discontinued on 11/18/2022.
2. No valid orders from a physician or other prescriber to discontinue the medications were found in the record of Resident #1.

Plan of Correction: Intensive Plan of Correction:
New, discontinued, or Modified Orders
? When Lansdowne Heights receives an order for a medication, the LPN will fax the copy of the order to the pharmacy to input to Point Click Care. The copy will be placed in the Orders Binder with a stamp indicating ?Faxed?, dated, and initialed.
? For new medications: The LPN will check the Orders Binder daily against Point Click Care and the medications that came from the pharmacy. Once the medications have been received, the LPN will confirm the order in Point Click Care and mark the copy in the binder with a stamp indicating ?Complete?, dated, and initialed.
? For discontinued medications: The LPN will check the Orders Binder daily against Point Click Care. Once the medication has been discontinued in Point Click Care, the LPN will confirm and mark the copy of the order in the binder with a stamp indicating ?Complete?, dated, and initialed. Medication will be removed from the Med Chart and returned to the pharmacy.
? For medication modifications: The LPN will check the Orders Binder daily against Point Click Care. If a new dosage for the medication is required, the LPN will follow steps for new medications above. If the frequency was changed, the LPN will confirm the changes in Point Click Care and mark the copy of the order in the binder with a stamp indicating ?Complete?, dated, and initialed.
? If there are orders that have not been confirmed or medications that have not been received within 24 hours, the LPN will follow up with the pharmacy and document in Progress Notes daily until resolved.
? The Director of Personal Care will audit this binder periodically.

Standard #: 22VAC40-73-690-G
Description: Based upon a review of records, the facility failed to document any action that was taken in response to the recommendations noted in the medication review that took place on 12/1/2022.
Evidence:
1.On 6/5/2023 LI conducted a focused monitoring inspection and reviewed the Pharmacy Drug Review. The Pharmacy Drug Review conducted on 12/2/2022 by a licensed health care professional practicing within the scope of his profession evidenced that a recommendation was made to the facility to submit to the pharmacy as soon as possible, a copy of a signed physician?s order sheet for Resident #1, the purpose of which is for the pharmacy to obtain refill authorization easily.
2. The last signed physician?s order sheet found in the record of Resident #1 was dated 2/2/2022.

Plan of Correction: ? The facility will write a progress noted within 30 days of receipt of the Pharmacy Drug Review and act in conjunction with the physician for the resident. The progress notes will be a follow-up for each resident that was identified in the report, what the suggestion was, and the recommendation of the physician.

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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