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. 14, 2023 and Aug. 17, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint 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 9:04 am on 8/14/2023 and exited at 2:40 pm. LI entered the facility at 9:53 am on 8/17/2023 and exited at 2:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/4/2023 regarding allegations in the area(s) of administration and administrative services, staffing and supervision, and resident care and related services. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 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 some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: administration and administrative services. A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based upon documents reviewed during a complaint inspection conducted on 8/14/2023 and 8/17/2023, the facility failed to implement their own policies and procedures regarding inventory of controlled medications. Evidence: On 8/17/2023 LI reviewed the following documentation: 1. The May 2023 Medication Administration Record and progress notes for Resident #1 evidenced that Resident #1 was administered Alprazolam 0.25 mg on 5/17/2023 at approximately 8:59 pm. 2. According to the pharmacy?s service and policy manual used by the facility, for all Schedule II medications, a Controlled Substances Declining Inventory Record is to be used to document administration of each individual resident?s Controlled Substance that includes the following information: quantity remaining, date and time of administration, and signature of person observing, assisting with, or administering the drug. 3.The Controlled Medication Utilization Record for the Alprazolam for Resident #1 did not document that the Alprazolam was administered on 5/17/2023 at approximately 8:59 pm, did not document the quantity that was left after the administration, and did not document the signature of the person administering the drug.
Plan of Correction:	Director of Clinical Services (DCS) will monitor the Controlled Medication Utilization Record weekly for the next 90 days, then routinely every month or as appropriate by DCS or designee. Medication Aides will be offered RMA refresher class. DCS will provide refresher in-service on medication management policies and standards.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based upon interviews the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety, or welfare of any resident. Evidence: 1. An interview with Collateral Contact #1 conducted on 8/4/2023 at approximately 10:41 am revealed that on 5/17/2023, the mother of Collateral Contact #1 fell in the facility on 5/17/2023 and later died in her room. 2.During the complaint inspection that took place on 8/14/2023 and 8/17/2023, LI interviewed the current administrator. The current administrator indicated to the LI there was no record that the facility submitted an incident report to the licensing division regarding the death of Resident #1.
Plan of Correction:	Executive Director (ED), Director of Clinical Services (DCS) and Assistant Director of Clinical Services (ADCS) educated on reportable per DSS guidelines and community policy. DCS will collaborate with ADCS in providing refresher staff in-service on reportable events and communications with community leadership. To make sure that the intervention and process are sustained, ED and clinical leadership will review resident incidents during weekly QA meetings to identify any pending follow ups or actions.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based upon a review of records and interviews, the facility failed to ensure that the resident?s record contained documentation of the resident?s refusal of medical attention when the resident has suffered a serious accident, injury, illness or medication condition, or there is reason to suspect that such has occurred. Evidence: During the complaint inspection conducted on 8/14/2023 and 8/17/2023, LI observed the following: 1. According to an interview with Staff #4 on 8/17/2023,Staff #4 attended to a fall involving Resident #1 at approximately 10:12 am on 5/17/2023 and Resident #1 told Staff #4 that she ?was walking felt weak and lowered herself to the floor.? Staff #4 stated that she asked Resident #1 more than once if she wanted to go to the hospital and that Resident #1 replied ?no I did not hit my head, I do not want to go to the hospital.? 2. According to an interview with Staff #1 on 8/14/2023 at approximately 11:50 am, Resident #1 had a fall on 5/17/2023 and that Staff #1 was called to assess Resident #1 for any injuries or medical issues. Staff #1 stated that the blood pressure for Resident #1 ?was low and that staff helped to get her up and into her recliner. Staff #1 stated that when Resident #1 was asked if she wanted to go to the hospital, she replied ?I can?t leave Barbara.? 3. According to interview with Collateral Contact #3 on 8/17/2023, the facility notified Collateral Contact #3 on 5/17/2023 of Resident #1?s fall on and of the resident?s refusal to be sent to the hospital for further evaluation. 4. Progress notes dated 5/17/2023 written at approximately 11:20 am and 1:02 pm did not evidence that Resident #1 refused medical treatment or refusal to go to the hospital.
Plan of Correction:	An alert and oriented resident experienced dizziness and lowered herself to the ground. Verbalized to staff that there was no pain or discomfort and denied any injury. BP was 106/71, O2 sat at 100% and temperature was 97.3. Director of Clinical Services (DCS) will provide a refresher in-service on notifying clinical leadership related to urgent clinical concerns such as refusal of treatment after an incident. To make sure that the intervention and process are sustained, ED and clinical leadership will review resident incidents during weekly QA meetings to identify any pending follow ups or actions.