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: April 25, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Technical Assistance:

N/A

Comments:

Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/25/2024 8:30 AM to 10:30 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 04/18/2024 regarding allegations in the areas of Resident Care & Related Services. Number of residents present at the facility at the beginning of the inspection: 104. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report, but identified during the course of the investigation can 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was signed by the resident or resident?s legal representative and the facility. Evidence: 1. In resident 1?s chart, the most recent ISP (dated as updated 8/22/2022) has no signature by staff, resident, or the resident?s legal representative. 2. Staff 1 confirmed that the unsigned copy reviewed with POA during the care plan meeting but couldn?t locate a signed copy.
Plan of Correction:	In respect to the specific resident/situation cited: Resident no longer resides in the community. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Director of Clinical Services or designee will review ISP?s of all current residents to ensure all are signed by the resident or the residents? legal representative. With respect to what systemic measures have been put into place to address the stated concern: Executive Director, Regional Director of Clinical Services or designee will conduct quarterly audits of the resident ISP?s to ensure service plans are signed timely. Date to be completed by: June 11, 2024
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, the facility failed to update the individualized service plan (ISP) annually. Evidence: 1. In Resident 1?s chart, admitted 08/25/2021, the most recent ISP is dated as updated 08/22/2022. 2. Staff 1 confirmed they could not locate an ISP dated later 08/22/2022.
Plan of Correction:	In respect to the specific resident/situation cited: Resident no longer resides in the community. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Director of Clinical Services or designee will review ISP?s of all current residents to ensure compliance with annual updates. With respect to what systemic measures have been put into place to address the stated concern: Executive Director, Regional Director of Clinical Services or designee will conduct quarterly audits of the resident ISP?s to ensure service plans are updated annually and as needed. Date to be completed by: June 11, 2024