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. 3, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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

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 (276) 206-0492.

Comments:

Type of inspection: Renewal 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 8:44 am on 8/3/2023 and exited at 3:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 103 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch and engaging in activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-40-A
Description:	Based upon a review of policies and observation made by LI during the renewal inspection conducted on 8/3/2023, the facility failed to ensure compliance with their own policies and procedures. Evidence: 1. At approximately 9:00 am on 8/3/2023, LI observed Staff #1 pour medications for Resident #1into a cup and then pour medications for Resident #2 into a separate cup. LI observed Staff #1 administer medications to Resident #1 at approximately 9:06 am and to Resident #2 at approximately 9:10 am on 8/3/2023. At approximately 9:15 am, LI observed Staff #1 pour medications for Resident #3 into a cup and then pour medications for Resident #4 into a separate cup. LI observed Staff #1 administer medications to Resident #4 at approximately 9:30 am and to Resident #3 at approximately 9:33 am on 8/3/2023. 2. According to the facility?s medication management policy under Nursing Policies and Procedures, ?RUI community nursing staff will refer to Omnicare?s Assisted Living Community Pharmacy Services and Procedures Manual for medication management and services. 3. According to page 93 of the Omnicare Assisted Living Community Pharmacy Services and Procedure Manual (Section 6.0 General Dose Preparation and Medication Administration) ?the community should only prepare medications for or administer medications to or observe or assist only one resident at a time.?
Plan of Correction:	Plan of Correction: 1. Staff education sessions will be held to educate the LPN/RMA staff on medication management policies. 2. Biannual Health Care Oversight will be conducted to assure adherence to the policy. Tools: 1. Nursing policies and procedures Manual-Medication Management and Services. 2. HealthCare Oversight Form.
Standard #:	22VAC40-73-680-H
Description:	Based upon a review of resident records and observations made by LI at the time of medication administration on 8/3/2023 during the renewal inspection, the facility failed to ensure that at the time medication is administered, the facility shall document on a medication administration record (MAR) all mediations administered to residents. Evidence: 1. LI observed Staff #1 administer medications scheduled for approximately 9:00 am on 8/3/2023 to Residents #1, #2, and #3. 2. The Medication Administration Records (MARS) for Residents #1, #2, and #3 evidenced no initials of Staff #1 who was observed by LI administering medications schedule for 9 am on 8/3/2023.
Plan of Correction:	Plan of Correction: 1. Staff education sessions will be held to educate the LPN/RMA staff on the medication administration and documentation policies. 2. Random audits will be conducted by the Clinical Director or designee weekly to ensure and enforce compliance. Tools: 1. Omnicare medication pass observation form.