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: Feb. 5, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 2/5/2020 Licensing Inspector (LI) conducted unannounced inspection in response to self-reported incidents. Resident records were reviewed. Possible violations were discussed at 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 #:	22VAC40-73-440-A
Description:	Based upon a review of records, the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed at least annually, and whenever there is a significant change in the resident's condition. Evidence: According to the records, the most recent Uniform Assessment Instrument (UAI) for Resident #6 was completed 1/3/2019 and the most recent UAI for Resident #7 was completed 7/26/18.
Plan of Correction:	Wellness Director/Assistant Wellness Director/and or Designee will ensure all current and future residents have Uniform Assessment Instruments (UAIs) completed upon admission, annually, and in the event of a significant change.
Standard #:	22VAC40-73-450-C
Description:	Based upon a review of resident records, the facility failed to ensure that the comprehensive individualized service plan shall be completed within 30 days after admission and shall include the following: Description of identified needs and date identified based upon the UAI. Evidence: The Individualized Service Plan (ISP) dated 10/1/19 for Resident #4, who was admitted to the facility on 9/29/19, indicates the resident needs physical assistance with dressing, toileting and transferring. The Uniform Assessment Instrument dated 10/31/19 for Resident #4 indicates the resident needs no help with dressing and toileting, and only mechanical assistance with transferring. The ISP dated 11/25/19 for Resident #5, who was admitted to the facility on 11/13/19, indicates the resident needs only mechanical assistance with toileting and transferring. The UAI for Resident #5 dated 11/13/19 indicates the resident needs no help with toileting (not even mechanical help) and needs mechanical help, human help, and physical assistance with transferring.
Plan of Correction:	Wellness Director/Assistant Wellness Director/and or Designee will review all current residents' Individualized Service Plans (ISPs). Any updates or changes will be made based on their needs identified on the Uniform Assessment Instrument (UAI). Wellness Director/Assistant Wellness Director/and or Designee will review and update ISPs annually and upon significant change. Wellness Director/Assistant Wellness Director/and or Designee will conduct an audit to ensure all ISPs are up to date.
Standard #:	22VAC40-73-450-F
Description:	Based upon a review of records and interview with staff, the facility failed to ensure that individualized service plans shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: According to the records, the Individualized Service Plan (ISP) for Resident #1 was last updated 9/3/18 and the ISP for Resident #2 was last updated 10/17/18.
Plan of Correction:	Wellness Director and Assistant Wellness Director will conduct an audit of current residents to ensure all Individualized Service Plans (ISPs) are accurate and current. Moving forward, Wellness Director/Assistant Wellness Director/or Designee will ensure ISPs are reviewed and updated every 12 months and as needed.