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. 28, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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: 2/28/2024 (10:35 AM - 1:40 PM). Complaints were received by VDSS Division of Licensing on 2/22/24 regarding allegations in the area(s) of: Administration and Administrative Services; Resident Care and Related Services. 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: Three Number of interviews conducted with residents: One Number of interviews conducted with staff: Two An exit meeting was conducted. 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: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the (complaint(s)/self-report) 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on record review and observation, the facility failed to ensure that medications or dietary supplements are not started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter and sample medications. Evidence: Resident #1's record and medications were observed during the inspection. Included among Resident #1's medications were Vitamin D 25mcg and Fludrocortisone 0.1mg. Resident #1's February MAR (medication administration record) stated that she began receiving one 0.1mg tablet of Fludrocortisone daily beginning on 2/23/24. The MAR also stated that Resident #1 began receiving one 25mcg tablet of Vitamin D daily beginning on 2/22/24. Resident #1's record did not contain signed physician's orders for Fludrocortisone or Vitamin D, at the time of the record inspection. Staff #1 confirmed that the signed orders were not in the chart, at the time of the chart observation.
Plan of Correction:	Not available online. Contact Inspector for more information.