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: Sept. 7, 2023

Complaint Related: Yes

Areas Reviewed:

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 9:57 am on 9/7/2023 and exited at 2:30 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 8/28/2023 regarding allegations in the area(s) of resident care and related services. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: A medication cart audit was conducted for the three residents whose records were reviewed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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) 479-5247or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based upon observation, interviews, and review of policies and procedures, the facility failed to ensure the implementation of the medication management plan regarding methods to prevent the use of outdated, contaminated medications, or illegible labels for one of three resident records reviewed. Evidence: 1. On 9/7/2023 Licensing Inspector (LI) observed medication stored in the medication cart for Resident 1 (R1) and found the following: ? A bottle of Creon with an expiration date of 6/20/2023 ? A bottle of Amlodipine, labeled to have 90 pills but upon pill count found to have 96 pills. ? A bottle of Telmisartan had an illegible label. 2. On 9/7/2023 at approximately 2:00 pm, LI interviewed Staff 1 (S1) who stated she had accepted medications from the family member of R1 that were not sealed. 3. On 9/7/2023 at approximately 2:00 pm LI interviewed Staff 4 (S4) who stated the family member of R1 had attempted to give S4 unsealed medications. S4 indicated she did not accept the medications and referred the family member to S1. 4. The facility?s Medication Management plan, under section methods to prevent the use of outdate, damaged, or contaminated medications documents ?The community should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels. The community should destroy all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with destruction guidelines. ?
Plan of Correction:	Intensive plan of correction: 1. Staff education sessions will be held to educate the LPN/RMA staff on the Medication Management Policies. Re-education will be held annually. Acting Director of Clinical Services, Assistant Director of Clinical Services (ADCS) and/or designee will implement the preventative measures. The Executive Director (ED), Director of Clinical Services (DCS), and ADCS will monitor the overall IPOC (Intensive Plan of Correction). 2. Biannual Health Care Oversight will be conducted to ensure adherence to the policy. RN will implement the preventative measures. The Regional Director of Clinical Services, ED, and DCS will monitor the overall IPOC. 3. All RMA?s will conduct self-audits of their assigned cart each shift they pass medications. The DCS, ADCS, and charge nurses will use the Omnicare General Medication Storage Guideline and audit form to conduct weekly audits of all medication carts in the community to ensure appropriate medication storage practices are being followed. The DCS, ADCS and/or designee will implement the preventative measures. The ED, DCS, ADCS will monitor the overall IPOC.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on records review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The June 2023 Medication Administration Record (MAR) documented that Resident 2 (R2) was to receive 12.5mg of Metoprolol as needed if heart rate was greater than 100. 2. The June 2023 MAR documented that on the following days the heart rate for R2 was greater than 100: 6/3/2023, 6/5/2023, 6/7/2023, 6/8/2023, 6/10/2023, 6/13/2023, 6/15/2023, and 6/16/2023. The MAR was blank for the administration of the prn order of Metoprolol 12.5mg to be given when heart rate was greater than 100.
Plan of Correction:	Intensive Plan of Correction 1. Staff education sessions will be held to educate the LPN/RMA staff on the Medication/Treatment Administration Policies. Re-education will be held annually. Director of Clinical Services (DCS), Assistant Director of Clinical Services (ADCS) will be responsible for implementing the preventative measures. Executive Director (ED), DCS, ADCS, Charge Nurse, and Registered Medication Aide will monitor the overall IPOC. 2. Biannual Health Care Oversight will be conducted to assure adherence to the policy. RN will implement the preventative measures. Regional Director of Clinical Services will monitor the overall IPOC. 3. Monthly Medication/Treatment Administration Observations to occur by a licensed nurse. DCS, ADCS, RN, and LPN will implement the preventative measures. DCS, ADCS will monitor the IPOC. 4. Quarterly 3rd Party Medication/Treatment Administration Observation to occur through Omnicare. Omnicare Representative will implement the preventative measures and monitor the overall IPOC. 5. Run a Medication Administration/Treatment Administration Report through EHR (3-5 times weekly) and follow up accordingly. Acting Director of Clinical Services and ADCS will implement the preventative measures and monitor the overall IPOC. 6. Annual RMA Refresher Course to be held by Omnicare. Omnicare Representative will implement the preventative measures. Omnicare representative, ED, and DCS will monitor the overall IPOC.
Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based upon record reviews, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions, were documented and were be maintained in the resident?s record. Evidence: 1. Physician?s order documented that R2 was to be weighed daily and the facility was to ?notify NP (nurse practitioner), cardiology, if weight is greater than 130 lbs or if there is a 3 lb weight gain within 24 hours. Call daughter if weight is 130. ? 2. June 2023 MAR documented weight for R2 at 126.5 lbs. on 6/14/2023 at approximately 11:00am and on 6/15/2023 weight was documented at 135.8 lbs at approximately 11:00 am. 3. Progress notes for R2 on 6/14/2023 and 6/15/2023 did not document that the NP, cardiology, or daughter were notified by the facility that the weight for R2 had reached 135.8 lbs. on 6/15/2023. 4. Progress notes documented that R2 ?complained of being tired? after lunch on 6/15/2023. On 6/16/2023 at approximately 12:25am, progress notes documented that R2 was having ?episodes of SOB (shortness of breath), oxygen reading was 82% and pulse was 64.? There was no documentation in R2?s record that the facility contacted the daughter, nurse practitioner, or cardiology of the weight gain.
Plan of Correction:	1.Director of Nursing (DON) or Designee to in-service LPN?s and Med Aides on how to verify that physicians? orders received are Assisted Living Appropriate by 12/20/2023. 2. If the order is inappropriate for Assisted Living, DON or Designee will clarify the orders with the physician prior to entering orders into Point, Click, Care.