VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lansdowne Heights, LLC
19520 Sandridge Way
Leesburg, VA 20176
(703) 936-7300

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Oct. 4, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

A non-mandated self-report inspection was initiated on 10/4/2021 and concluded on 10/25/2021. A self-reported incident was received by the department regarding allegations in the areas of resident supervision. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-40-A
Description:	The facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence: Based on interview and documentation review the facility did not comply with local fire ordinance. On 8/25/2021 a sofa was placed in front of the main entrance/exit door to the safe secure environment. This door is required to be unblocked at all times.
Plan of Correction:	The community will conduct an in-service for all director care staff on keeping fire exits clear at all times.
Standard #:	22VAC40-73-460-D
Description:	Based on interview and documentation review the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: On 8/22/2021 at 12:20am Resident #1 exited the safe secure environment without staff supervision.
Plan of Correction:	The Uniform Assessment Instrument (UAI) and Individualized Service Plan (ISP) for Resident #1 were updated to reflect the significant change in the resident?s condition. The Director of Personal Care (DPC), or designee will update ISP and UAI for Resident #1 if there is a significant change in care.
Standard #:	22VAC40-73-870-E
Description:	Based on interview and documentation review the facility failed to ensure that all equipment shall be kept clean and in good repair and condition. Evidence: On 8/25/2021 the locking mechanism to the safe secure environment failed and resulted in Resident #1 exiting the safe secure environment without supervision.
Plan of Correction:	The community has repaired the identified equipment on 8/22/2021. The equipment was inspected on 9/15/2021. The maintenance director, or designee will inspect the identified equipment monthly.