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: Dec. 14, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring 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 8:20 am on 12/14/2023 and exited at 10:52 am. 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: 109 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. 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.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-B
Description:	Based upon interview and observation of medication administration conducted by LI (licensing inspector) on 12/14/2023 during a focused monitoring inspection, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached until administered to four out of four residents. Evidence: 1. At approximately 8:40 am LI witnessed Staff 1 (S1) retrieve from the left lower drawer of the medication cart, medications that had been poured into an unlabeled cup for Resident 1 2. At approximately 8:55 am, LI witnessed S1 retrieve from the left lower drawer of the medication cart, medications that had been poured into an unlabeled cup for Resident 2. 3. At approximately 9:02 am, LI witnessed Staff 1 retrieve from the lower left drawer of the medication cart, medications that had been poured into an unlabeled cup for Resident 3. 4. At approximately 9:11 am, LI witnessed Staff 1 retrieve from the lower left drawer of the medication cart, medications that had been poured into an unlabeled cup for Resident 4. 5. Staff 1 stated during interview with LI at approximately 9:15 am that she did pre-pour medications.?
Plan of Correction:	1.Staff will be in-serviced by 12/20/2023 on medication management policies. 2. Biannual Health Care Oversight will be conducted to assure adherence to the policy. 3. Director of Nursing or Designee will randomly audit compliance to medication management policies and procedures until 1/20/2024. 4. A copy of the Medication Management policies have been placed in each medication cart. 5. Community will utilize re-education and the RUI Disciplinary Action process for each RMA should non-compliance continue.