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

Current Inspector: Marshall G Massenberg (703) 431-4247

Inspection Date: Sept. 24, 2020 and Sept. 28, 2020

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
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

Comments:
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia.

A monitoring inspection was initiated on 9/24/2020 and concluded on 9/28/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 69. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, staff work schedule for two weeks, the annual health and fire inspections, fire drill reports, healthcare oversight reports, and dietary oversight reports submitted by the facility to ensure documentation was complete. Criminal Background Checks of all staff hired since the previous inspection conducted on 8/19/2019 were reviewed.

Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

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 #: 22VAC40-73-680-H
Description: Based upon a review of resident records, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.

Evidence: On 9/9/2020 medications to be administered to Resident #2 at approximately 8:00 pm were not documented on the MAR. The facility was able to provide evidence through other documentation that the medications were administered. The following medications were given but not documented on the MAR as being administered: Tylenol Extra Strength 500mg;Trazadone 50mg; Dulcolax Suppository 10mg; Flomax 0.4mg; Melatonin 3mg; Neurontin Capsule 100mg; Sodium Chloride Nebulization Solution 0.9%; and Morphine Sulfate Solution 20mg/mL.

Plan of Correction: Wellness Director along with Assistant Wellness Director will provide training to all charge nurses showing how to review PCC orders, and monitor certified medication aides order administration sign off for each shift. Director of Nursing or Assistant Director of Nursing will randomly check to ensure all medications are signed off on the MARS as ordered. This audit will be performed on all shifts to ensure medication administration compliance.

Standard #: 22VAC40-73-680-I
Description: Based upon a review of resident records, the facility failed to ensure that the Medication Administration Records (MARS) included for "as needed" PRN medications: the effectiveness.

Evidence: Resident #1 was given a PRN medication on 9/23/2020 at approximately 2:11 pm. The effectiveness of the medication was not noted on the MAR. Resident #3 received a PRN medication on 9/24/2020 at approximately 10:40 am. The effectiveness of the medication was not noted on the MAR.

Plan of Correction: Director of Nursing and Assistant Director of Nursing will provide training to all charge nurses making them aware that all PRN orders must indicate follow up in 1 hour as well as to notify medical director (MD) if PRN medications are not effective. Director of Nursing will communicate to all providers that when writing an order for a PRN medication that monitor for effectiveness must be included as well as what to do if PRN medication is not effective. Director of Nursing, Assistant Director of Nursing and charge nurse will add follow up in 1 hour for effectiveness of PRN medications document results will be added to all PRN medications. Notify the MD if PRN medications are not effective and document all new orders and or/interventions appropriately.

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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