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: May 10, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Technical Assistance:

Resident centered care including personalization of goals and services.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/10/2024: 8:55 AM to 1:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/05/2024 regarding allegations in the area of: Resident Care and Related Provisions. Number of residents present at the facility at the beginning of the inspection: 103. Number of resident records reviewed: 1 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all the self-report; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services, Personnel, and Resident Accommodations and Related Provisions. A violation notice was issued; any violation(s) not related to the self-report 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review and staff interview, the facility failed to ensure that each staff person required to be evaluated annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form. Evidence: 1. Staff 2, hired on 07/29/2019, did not have a completed annual screening in her staff record. 2. Staff 3?s, hired on 03/02/2023, record did not have a completed annual screening. The last screening was completed on 03/02/2023. 3. Staff 1 confirmed that staff 2 and 3?s tuberculosis screening was not completed annually. Evidence: 1. Staff 2, hired on 07/29/2019, did not have a completed annual screening in her staff record. 2. Staff 3?s, hired on 03/02/2023, record did not have a completed annual screening. The last screening was completed on 03/02/2023. 3. Staff 1 confirmed that staff 2 and 3?s tuberculosis screening was not completed annually.
Plan of Correction:	In respect to the specific resident/situation cited: TB screening for Staff 1 and 2 were updated. 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 TB screenings of all current staff members 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 staff TB screenings to ensure they are updated annually. Date to be completed by: June 30, 2024
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review and staff interview, the facility failed to ascertain prior to admission whether a potential resident staying greater than three days is a registered sex offender and document this information in the resident?s record. Evidence: 1. Staff 4 provided a list of all sex offender checks for residents on the special care unit. 2. Resident 2 and Resident 3 did not have completed sex offender checks. 3. Staff 4 confirmed that the sex offender checks for Residents 2 and 3 were not completed.
Plan of Correction:	In respect to the specific resident/situation cited: Sex offender registry was pulled for Resident 2 and 3. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Executive Director or designee will review sex offender registry of all current residents to ensure compliance. With respect to what systemic measures have been put into place to address the stated concern: Executive Director or designee will conduct quarterly audits of resident files to ensure registry is on file. Date to be completed by: June 30, 2024
Standard #:	22VAC40-73-450-E
Description:	Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the resident or the resident?s designee. Evidence: 1. Resident 1?s ISP was signed by Staff 1 on 03/25/2024. 2. Resident 1?s ISP did not include a resident or their designee?s signature. 3. Staff 1 confirmed they did not have a copy of the ISP signed by the resident or the resident?s designee.
Plan of Correction:	In respect to the specific resident/situation cited: ISP for Resident 1 was reviewed and signed by the responsibly party. 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 30, 2024
Standard #:	22VAC40-73-550-G
Description:	Based on record review and staff interview, the facility failed to ensure that resident rights were reviewed with staff annually and filed in the staff?s record with the evidence including a written acknowledgement of being informed with the date of review. Evidence: 1. Staff 3?s, hired on 03/02/2023, records did not have an annual review. The last review was completed on 03/27/2023. 2. Staff 4 confirmed that the resident rights had not been completed annually.
Plan of Correction:	In respect to the specific resident/situation cited: ISP for Resident 1 was updated to include frequency of rounding. 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 memory care residents to ensure compliance. 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 ISP to ensure service plans are accurate. Date to be completed by: June 30, 2024
Standard #:	22VAC40-73-550-G
Description:	Based on record review and staff interview, the facility failed to ensure that resident rights were reviewed with staff annually and filed in the staff?s record with the evidence including a written acknowledgement of being informed with the date of review. Evidence: 1. Staff 3?s, hired on 03/02/2023, records did not have an annual review. The last review was completed on 03/27/2023. 2. Staff 4 confirmed that the resident rights had not been completed annually.
Plan of Correction:	In respect to the specific resident/situation cited: Resident rights were reviewed with Staff 3. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Human Resources Manager or designee will conduct resident rights training for all staff members. With respect to what systemic measures have been put into place to address the stated concern: Executive Director, Human Resources Manager or designee will conduct quarterly audits of resident rights training to ensure compliance. Date to be completed by: June 30, 2024
Standard #:	22VAC40-73-930-D
Description:	Based on record review and staff interview, the facility failed for each resident with an inability to use the signaling device, to ensure the resident?s individualized service plan (ISP) specified a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated needs. Evidence: 1. Resident 1 currently resides in the facility?s special care unit and is unable to utilize a call bell or pendent. 2. Resident 1?s ISP did not contain a focus or goal regarding rounding. 3. Staff 1 confirmed that resident was unable to use a call bell or pendant. 4. Staff 1 stated that all direct care staff complete rounds every two to three hours and confirmed that the frequency of rounding was not written on the ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.