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: July 29, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2- (18) FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/29/2024-07/30/2024, 10:50 am- 3:45 pm, 11:30 am-2:40 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Collateral Interview: 1, (CB) Observations by licensing inspector: Meals, Activities, Medication Pass An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined noncompliance with applicable standard(s) or law, and violations were documented on the violation notice issued to the facility. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397 3017 or by email at Jacquelyn.Kabiri@DSS.virginia.gov

Violations:

Standard #:	22VAC40-73-350-C
Description:	Based on record review and staff interview, the facility failed to obtain written acknowledgment that each resident or his legal representative is fully informed at time of admission and annually to exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered pursuant to Chapter 9 of Title 9.1 of the Code of Virginia, including how to obtain such information. Evidence: 1. The facility failed to provide documentation of initial or annual receipt of information pertaining to the sex offender registry and how to obtain such information. 2. Staff 1 verified this was not completed initially or annually for any residents.
Plan of Correction:	Community Administrator, Director of Nursing, and Case Manager will review all current resident?s administrative files for annual sex offender acknowledgment signatures. Signatures will be obtained as need for identified residents as well as any additional residents. Community will send out reoccurring annual acknowledgment for all current resident?s responsible parties during the month of April.
Standard #:	22VAC40-73-450-E
Description:	Based on the Resident record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or designee, and by his resident or legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. The following resident ISP were not signed and dated by the licensee, administrator, or his legal representative. A. Resident 6?s ISP was revised on 5/29/2024. B. Resident 7?s ISP was revised on 05/14/2024. C. Resident 2?s ISP was revised on 03/30/2024. D. Resident 8?s ISP was revised on 05/14/2024. E. Resident 9?s ISP was revised on 06/06/2024. 2.Staff 2 and 3 interviews with the licensing inspector (LI) determined that ISPs are electronically emailed and not signed.
Plan of Correction:	Community Administrator, Director of Nursing, and Case Manager will review all current resident?s individualized care plans for appropriate signatures. Signatures will be obtained for identified residents as well as any additional residents. Administrator will review monthly any completed individualized care plan for appropriate signatures.
Standard #:	22VAC40-73-640-D
Description:	Based on direct observation, the facility failed to have readily accessible at least one pharmacy reference book, drug guidebook, or medication handbook for nurses that is no more than two years old as a reference. Violations: 1. The medication room had a reference book dated 2020. 2. Photo taken as evidence.
Plan of Correction:	Community has purchased pharmacy booklet and provided to nursing team. Community has bookmarked updated reference book website on electronic medical record computer for quicker assess to updates.
Standard #:	22VAC40-73-700-1
Description:	Based on the review of Resident records, the facility failed to ensure that a physician's order included the source of oxygen, such as compressed gas or concentrators, on an oxygen order. Evidence: 1. Resident?s 11and 12, had a signed physician order on file for oxygen. 2. The physician?s order did not specify compressed gas or concentrators.
Plan of Correction:	Community has received and updated all O2 orders to include the source. DON or wellness nurse to communicate with prescribing MD if new orders do not include source of O2.
Standard #:	22VAC40-73-700-2
Description:	Based on direct observation, the facility failed to ensure that ?No Smoking-Oxygen in Use? signs are posted in or on any room where oxygen is in use. Evidence: 1. Resident 1?s record contained an oxygen order from 10/26/2023, but no oxygen notification sign was posted for the resident?s room. 2. Resident 11?s record contained an oxygen order from 10/16/2023, but no oxygen notification sign was posted for the resident?s room. 3. Resident 12?s record contained an oxygen order from 10/16/2023, but no oxygen notification sign was posted for the resident?s room.
Plan of Correction:	Community has reviewed all charts and placed ?No smoking O2 in use? signs outside appropriate rooms. Administrator or designee will place ?No Smoking O2 in Use? signs in shadow box outside of rooms. Monthly review of O2 usage will be conducted to ensure compliance.