VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Meadow Glen of Leesburg
315 Dry Mill Road
Leesburg, VA 20175
(703) 737-6149

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: June 6, 2024

Complaint Related: No

Areas Reviewed:

AREAS OF STANDARDS 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 63.2- (17) LICENSURE AND REGISTRATION PROCEDURES 63.2- (18) 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

Comments:

The date of inspection: 06/06/2024, 08:55-12:30. 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: 39. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3. Number of staff records reviewed: 4. Number of interviews conducted with residents: 3. Number of interviews conducted with staff: 1. Observations by licensing inspector: Meals, Activities, Medication Pass 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

Violations:

Standard #:	22VAC40-73-550-G
Description:	Based on record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents were reviewed annually with each staff person. Evidence: 1. Staff 2?s review of right?s and responsibilities of resident?s in assisted living facilities were completed on 2/13/2023. 2.Staff 3?s review of rights and responsibilities of residents in assisted living facilities were completed on 3/18/2023. 3. Staff 4 confirmed that the review of resident?s rights and responsibilities had not been completed annually. Staff 2?s review of right?s and responsibilities of resident?s in assisted living facilities was completed on 2/13/2023.
Plan of Correction:	The Business Office Manager has incorporated resident rights into the annual training schedule and created a log to document this. A reminder has been set in the calendar to ensure all staff members review resident rights yearly. The Executive Director will oversee this process by reviewing the log annually to confirm that all training is current. During the monthly meeting on June 27th, 2024, the staff reviewed and signed off on the resident rights, ensuring compliance and awareness among all employees. Completed 6/28/2024
Standard #:	22VAC40-73-560-E
Description:	Based on direct observation and staff interview, the facility failed to ensure that all resident records were stored in a locked area. Evidence: 1. Staff 3?s medication cart, located outside the game room, had a pharmacy delivery sheet dated 6/5/2024, with resident 1?s name and medication order visible. 2. Staff 4 removed the confidential information from the medication cart and took it with her.
Plan of Correction:	On June 6, 2024, the Executive Director trained all staff members to ensure that residents' records are always kept locked. Following this training, any unsecured resident records were immediately removed to maintain compliance with privacy standards. The Relias training program provides comprehensive education on HIPAA regulations and the importance of securing information. To reinforce this training, the Business Office Manager will include a yearly reminder to staff about this education. Completed on 6/6/2024