VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ashleigh at Lansdowne
44124 Woodridge Parkway
Leesburg, VA 20176
(703) 828-9600

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Aug. 19, 2019 and Aug. 20, 2019

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.

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at 703-934-1505.

Comments:

An unannounced renewal study was conducted on 08/19/2019 and 8/20/2019. At the time of entrance 77 residents were in care. The sample size consisted of ten resident records, five staff records, and four individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 6/28/18 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including chair exercises and balloon toss. Medication administration was observed. Possible violations were discussed during the exit interview. 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 #:	22VAC40-73-1180-B
Description:	Based upon observation during the renewal inspection, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: On the safe and secure care unit, the door to the laundry room was unlocked and opened. Inside the room were materials and objects that may have been harmful to residents (including laundry detergent).
Plan of Correction:	Hinge to laundry room door had the tension adjusted so that is closed completely upon entering and exiting the space. Maintenance Director assessed all other doors on the special care unit, which by regulation needed to be secured for resident safety, to be sure they were functioning properly. Assessment of these doors by maintenance will continue during daily rounds in the building.
Standard #:	22VAC40-73-930-D
Description:	Based upon a review of resident records and interviews with staff, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: this inability shall be included in the resident's individualized service plan. Evidence: The Individualized Service Plans (ISPs) for Residents #3, #4, #5, #7, and #8 did not include their inability to use the call bell system, in addition to other services.
Plan of Correction:	Residents will be assessed by the Wellness Director/Assistant Wellness Director or their designee for their ability to use their signaling devices and other services. Those deemed incapable will have this documented on their ISP by the Wellness Director or Assistant Wellness Director, to include how the staff will check on these particular residents.