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: Aug. 14, 2023 and Aug. 17, 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 9:04 am on 8/14/2023 and exited at 2:40 pm. LI entered the facility at 9:53 am on 8/17/2023 and exited at 2:25pm. 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 8/2/2023 regarding allegations in the area(s) of resident care and related services. Number of resident records reviewed: 7 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication administration was observed on 8/14/2023. 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) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based upon documentation, the facility failed to ensure prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1.An incident report for Resident 6 (R6) dated 8/11/2023 stated ?Around 05:45 associate state that resident found on the floor, on arrival resident lying on the floor on her right side next to the bed.? 2.Call-bell reports reviewed showed that on 8/11/2023 at approximately 05:17 am R6 pressed her call bell pendant and there was no response until 25 minutes and 48 seconds later.
Plan of Correction:	1. Director of Nursing (DON) or Designee to in-service staff on importance of timely response, how to reset pendants, and their accountability to respond timely. 2. DON or designee will monitor to ensure compliance to an average of 10 minutes response time. 3. DON or designee will review response times daily until 1/20/2024 to monitor compliance.
Standard #:	22VAC40-73-680-B
Complaint related:	No
Description:	Based upon observation and interview, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. LI Lunceford and the ED observed at 10:03 am on 8/14/2023, three separate cups of medications in the top drawer of the medication cart. 2. Staff 1 admitted to LI that she had pre poured medications and put them in the medication cart for rooms 302, 303, and 324. The medications were in cups labeled with room numbers.
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. DON 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.
Standard #:	22VAC40-73-680-C
Complaint related:	No
Description:	Based upon observations, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility?s scheduled dosing schedule for two out of two residents. Evidence: 1. On 8/14/2023, Licensing Inspector (LI) Lunceford and the Executive Director (ED) observed Staff 1 administer four medications to one resident on the third floor. The medications were observed to be administered at approximately 10:00 am. The MAR indicated that the medications were to be administered at approximately 8:00 am. 2. On 8/14/2023 LI Lunceford and ED observed Staff 2 administered four medications to one resident on the fourth floor. The medications were observed to be administered at approximately 10:00 am. The MAR indicated that the medications were to be administered at approximately 8:00 am.
Plan of Correction:	1. Staff will be in-serviced by 12/20/2023 on medication management policies. 2. Medication Administration times have been reviewed and adjusted to gain compliance to medication management policies. 3. DON or designee will review compliance with medication management policies weekly until 1/20/2024. 4. DON or designee will randomly audit compliance to medication management policies and procedures thereafter until 2/20/2024. 5. A copy of the Medication Management policies have been placed in each medication cart.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based upon record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Physician?s orders for Resident 5 (R5) dated 7/27/2023, indicated a dry weight to be 209 lbs. and torsemide 20mg to be given if weight was recorded to be more than 3 lbs. over the dry weight and torsemide 40mg to be given if weight was recorded to be more than 5 lbs. over the dry weight. 2. Progress notes for R5 dated 8/9/2023 at approximately 1:26 pm signed by the practitioner stated, ?Weight today is 216 lbs., dry weight is 208. Per nursing records prn torsemide order resident was given 20mg once on 8/7/2023 when weight recorded that day is 215 lbs. (which is 7 lbs. over the dry weight). Weight has been elevated for days and yet no prn torsemide given per orders and if was given was not the right dose. Medication not given as ordered.? Progress notes for 8/9/2023 at approximately 3:25 pm signed by the nurse practitioner indicated that R5 was sent to the ER (emergency room) for ?cardiopulmonary overload and congestive heart failure.? 3. August 2023 MAR for R5 indicated, 40mg torsemide is to be administered if weight gain is greater than 5 lbs. On 8/7/2023 the documented weight on the MAR for Resident #5 was 215 lbs., 6 lbs. greater than the dry weight of 209 lbs. on the physician?s order written 7/27/2023. R5 was administered 20mg of prn torsemide at approximately 3:39 pm on 8/7/2023. 4. August 2023 MAR for R5 indicated that on 8/8/2023 and 8/9/2023 staff did not administer as needed (prn) 40 mg torsemide to R5 when documented weight was five pounds greater than dry weight of 209 lbs. R5?s documented weight on 8/8/2023 was 216 lbs. and on 8/9/2023 the documented weight was 217 lbs.
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-I
Complaint related:	No
Description:	Based on documentation, the facility failed to ensure the MAR included initials of direct care staff administering medications and any medication errors or omissions. Evidence: 1. The July 2023 MAR was blank for the administration of Gabapentin on 7/11/2023 at approximately 1:30 pm for R5, and there was no documentation that the medication was omitted. 2. The August 2023 MAR was blank for the administration of Levothyroxine on 8/9/2023 at approximately 6:00 am, and there was no documentation that the medication was omitted.
Plan of Correction:	1. Staff will be in-serviced by 12/20/2023 on medication management policies. 2. DON or designee will randomly audit compliance to medication management policies and procedures until 1/20/2024. 3. A copy of the Medication Management policies have been placed in each medication cart.