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Licensed Care / Search Licensing Programs / Assisted Living Facility Search
102 Desmond Plaza SE
LEESBURG, VA 20175
571-224-9516
| Inspection Dates: | 10/07/2025 |
|---|---|
| Complaint Related: | NO |
| Inspector: | Amanda Velasco: (703) 397-4587 |
Type of inspection: ¿Monitoring¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/07/2025, 10:30 a.m. to 2:40 p.m. 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: 43 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 and 1 partial for medication audit. Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and movies Additional Comments/Discussion: none 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Description: Based on observations made during a tour of the building, the facility failed to ensure the interior of the building shall be maintained in good repair and kept clean and free of rubbish. Evidence: 1. The Licensing Inspector (LI) observed the following during the facility tour: a. A set of blinds in resident 5 's room were torn and broken, held together at one end with a rubber band. 2. In the Blue Ridge Cafe: a. A brown wall divider had three veneer squares intact, while the fourth square was missing. Glue residue was visible where the missing square had once been. b. A set of wooden blinds had a broken area. c. The paint on the walls was scratched and marked in the dining area. 3. The main kitchen door was stained and marked with scrapes and yellow discoloration. 4. The door to Room 215 had large black scratches across the middle. 5. The carpet in front of room 208 had a long white stain. 6. The main door near the salon had black scrapes and areas where paint had been scraped off the middle section. 7. Photo evidence taken.
The community is undergoing renovations. New paint work was started on 10/13/2025 to refresh the community. Window blinds that were missing torn in resident 5’s room and dining room were replaced immediately. Regular spot cleaning for carpets and monthly carpets shampooing as applicable will be conducted by the Maintenance Director.
Description: Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. Resident 1 had an admission date of 07/14/2025 and the resident's record did not contain a Sex Offender Screening. 2. Resident 2 had an admission date of 09/15/2025 and the resident's record did not contain a Sex Offender Screening. 3. Resident 4 had an admission date of 08/31/2024 and the resident's record did not contain a Sex Offender Screening 4. During an interview with Staff 1 and Staff 2, they were unable to locate the sex off ender screenings at the time of the inspection.
A new sex offender check was conducted for resident 1, 2, and 4 which was updated immediately to be included in their administrative chart. An audit was completed for all residents to ensure registered sex offender search was completed and on their file by 10/10/2025. Administrative Assistant will ensure sex offender registry will be checked for all incoming residents.
Description: Based upon observation, the facility failed to ensure that medications shall remain in the pharmacy-issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. On 10/07/2025, at approximately 12:38 p.m., the Licensing Inspector (Ll) audited the medication cart and observed that the prescription medication BREO Ellipta inhalation powder inhaler was not contained in a box with identifiable resident information. 2. Staff 4 conformed the inhaler was not in a prescription box and belonged to resident 6. 3. Photo evidence taken.
Director of nursing removed all meds do not have identifiable resident information and obtain new medication orders if applicable. Medication cart audits will be conducted weekly by the med tech and followed up by DON to ensure compliance with pharmacy issued containers and label. Pharmacy medication audits will also be done monthly. DON will ensure compliance by 11/01/2025.
Description: Based on direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are in a locked area. Evidence: 1. On 10/07/2025, at approximately 10:08 a.m., the Licensing Inspector (LI) observed that resident 4's bathroom in the memory care facility contained one bottle of Listerine mouthwash, one spray bottle of Downy Wrinkle Releaser, two cans of Lysol disinfecting spray, and two bottles of body lotion, all stored in an unlocked area. Resident 4 also had a desk in the bedroom with a cup containing two pairs of scissors, which was also in an unlocked area. 2. At approximately 12:29 p.m., the Licensing Inspector (LI) observed one white glass bottle of Old Spice aftershave, one bottle of Adidas aftershave, and one green disposable razor stored in an unlocked cabinet in resident 5's bathroom within the memory care facility. 3. Photo evidence taken.
All hazardous materials were locked away immediately in resident 4 and 5’s room. Families were notified immediately to ensure hazardous materials are locked away in the cabinet under the sink when visiting their loved ones. In addition, weekly rounds will be completed by the DON, ED, and Maintenance director to ensure compliance with hazardous materials being locked away. All cleaning supplies and other hazardous materials will be locked away by 11/07/25.
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