Lansdowne Heights, LLC — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Lansdowne Heights, LLC was inspected 25 times between August 4, 2021 and May 20, 2026 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 14 with none. Across that history VDSS cited 25 violations under 19 distinct standards. 8 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 23 of these 25 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

09/11/2026

Administrator

Justin Roberts

Licensing inspector

Amanda Velasco

Inspector phone

(703) 397-4587

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 20, 2026Inspection3 violations

Inspection dates

05/20/2026

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical assistance

70-C: Incident Reports 1130-C: Awake and On Duty 330: Shift Communication Logs

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: 05/20/2026 8:50 AM to 10:06 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 04/20/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident and Staff records related to the incident. Additional Comments/Discussion: Resident was not at facility at time of inspection for interview. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.

Violations

22VAC40-73-470-F

Based on resident record review and staff interview, the facility failed to ensure that medical attention from a licensed health care professional was secured immediately when the resident suffers a serious accident, injury, illness, or medical condition.

Evidence

On 04/20/2026, the facility reported an incident that occurred on 04/19/2026 in which Resident 1 fell and was placed back in bed following the discovery of Resident 1 on the floor of the bathroom. The report states that Resident 1 was sent to the hospital on 04/19/2026. In the follow-up report, dated 04/29/2026, the facility stated that Resident 1 fell on 04/17/2026 and was located by Staff 2 who notified Staff 3, the staff person in charge, at the time of the incident. The report stated that Staff 3 did not report the incident, and asked Staff 2 not to disclose upon notification that Resident 1 was at the hospital with a fracture.
Resident 1’s progress notes did not include documentation of the incident that occurred on 04/17/2026. Resident 1’s progress notes do include PRN administration of pain medication on 04/18/2026, and documentation on 04/19/2026 of Resident 1 being sent out to the hospital due to tremors, poor body alignment, and Resident 1 only opening Resident 1’s left eye during assessment. The progress note stated that Resident 1 appeared to be in pain.
Staff 2 and Staff 3’s written statements were reviewed. Staff 2’s statement indicates that Staff 2 entered Resident 1’s room around 10:00 AM and found Resident 1 on the bathroom floor. Staff 2’s statement describes Resident 1 as conscious but struggling to stand. Staff 2’s statement confirms that Staff 2 called Staff 3 to Resident 1’s room, where Staff 3 and Staff 2 assisted Resident 1 off the floor and to the toilet before Staff 3 left the room without completing an assessment. Staff 2’s written statement confirmed that Staff 2 did not document the fall.
Staff 3’s statement confirms that Staff 3 was called to Resident 1’s room where Staff 2 and Staff 3 assisted the resident off the bedroom floor and returned Resident 1 to bed.
A time-stamped document included with Staff 2 and Staff 3’s statements, prepared by Staff 4, indicates that Staff 3 entered Resident 1’s room at 9:59 PM and left at 10:02 PM.
In an interview with the LI on 05/20/2026, Staff 1 stated that their procedures following a fall were not completed. Staff 1 confirmed that Resident 1 did not receive immediate medical attention after an incident, specifically a fall, occurred on 04/17/2026.

Plan of correction

Staff Training and Compliance Action The following actions and outcomes were documented regarding Staff 3’s training, policy awareness, and employment status: • Staff 3 was trained on and acknowledged the proper procedures for responding to and reporting falls within the community. • Staff 3 stated that he was aware of the company’s policies and procedures but failed to comply with them. • As a result, Lansdowne Heights reported Staff 3 to the Virginia Board of Nursing and terminated his employment. Follow-Up Care and Medical Referral Despite the limited information provided by Staff 3, the oncoming nurse delivered appropriate pain management care to the resident in accordance with company policies and procedures. Based on the nurse’s follow-up assessment and the resident’s significant change in condition, the resident was sent for further medical evaluation. Ongoing Staff Education Lansdowne Heights will continue to provide staff orientation and follow-up continuing education meetings on fall procedures to reinforce expectations and promote ongoing compliance.

22VAC40-73-40-A

Based on resident record review and staff interviews, the facility failed to ensure compliance with the facilities’ own policies and procedures.

Evidence

On 04/20/2026, the facility reported that Resident 1 had an undocumented, unwitnessed fall that resulted in the resident being sent to the hospital on 04/19/2026. The follow up report, dated 04/29/2026, indicates that Resident 1 fell on 04/17/2026, and that Staff 2 and Staff 3 had failed to report the incident.
On 05/20/2026, Staff 1 provided a copy of the Falls Protocol and Falls Protocol checklist. The protocol indicates that a head-to-toe assessment must be completed first, including LOC, pupils, injuries, behaviors, full set of vitals, and PMS in extremities. The second and third steps include addressing bleeding and/or wounds as appropriate. The fourth through seventh step indicate required contacts including the provider, 911, family or POA, and identified facility leadership. The eighth step includes documenting in the electronic record to include a detailed incident note, vital signs, and a falls form update. Follow-up should be completed at 24 hours, 72 hours, and seven (7) days.
A written statement from Staff 2 states that a head-to-toe assessment was not completed. Staff 3’s statement indicates that vitals were not completed on 04/17/2026 or 04/18/2026. Statements written by Staff 2 and Staff 3 state that documentation of the incident was not completed.
Resident 1’s progress notes did not include documentation of a fall on 04/17/2026, as confirmed by the written staff statements.
Staff 3’s record included a termination notice, dated 04/21/2026, that stated Staff 3 was terminated due to not following facility procedures and protocol.
In an interview with the LI on 05/20/2026, Staff 1 confirmed that Staff 2 and Staff 3 failed to follow facility policies and procedures related to falls protocol after Resident 1 had a confirmed fall on 04/17/2026 resulting in a fracture.

Plan of correction

22VAC40-73-460-F

Based on resident record review and staff interview, the facility failed to ensure the next of kin, legal representative, designated contact person of any incident of a resident falling or wandering from the premises.

Evidence

On 04/20/2026, the facility reported that Resident 1 had an undocumented, unwitnessed fall that resulted in the resident being sent to the hospital on 04/19/2026. The follow up report, dated 04/29/2026, indicates that Resident 1 fell on 04/17/2026, and that Staff 2 and Staff 3 had failed to report the incident.
Statements written from Staff 2 and Staff 3 confirm that the incident was not reported and/or documented in the residents’ records.
Resident 1’s progress notes do not include documentation of communication with Resident 1’s preferred contact after Resident 1’s fall on 04/17/2026.

Plan of correction

December 22, 2025Inspection0 violations

Inspection dates

12/22/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical assistance

325

Comments

Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 12/08/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/22/2025 2:00 PM to 3:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 2 Observations by licensing inspector: Resident records. Additional Comments/Discussion: Resident was not on site at time of inspection. 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 10, 2025Inspection1 violation

Inspection dates

11/10/2025

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Comments

Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/03/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/10/2025 10:50 AM to 12:00 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: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Video Footage, Staff Clock In Area, Nurse’s Station Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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

22VAC40-73-460-D

Evidence

On 11/03/2025, the facility submitted a reportable incident in which Staff 3 let Resident 1 out of the unit accidentally, resulting in Resident 1 entering the parking lot and being returned to the facility by Staff 4 within two minutes after exiting the building.
On 11/10/2025, Staff 1 reviewed the video footage with the LI that confirms the information submitted in the report.
In an interview with the LI, Staff 1 stated that Staff 3 had been out of the building when Resident 1 was admitted, and this was Staff 3’s first night in the building. Staff 3 confirmed supervision was not provided to ensure attention to specialized needs such as wandering from the premises.

Plan of correction

Based on resident record review, video footage observation, and staff interview, the facility failed to ensure supervision of resident care including attention to specialized needs such as wandering from the premises. Evidence: 1. On 11/03/2025, the facility submitted a reportable incident in which Staff 3 let Resident 1 out of the unit accidentally, resulting in Resident 1 entering the parking lot and being returned to the facility by Staff 4 within two minutes after exiting the building. 2. On 11/10/2025, Staff 1 reviewed the video footage with the LI that confirms the information submitted in the report. In an interview with the LI, Staff 1 stated that Staff 3 had been out of the building when Resident 1 was admitted, and this was Staff 3’s first night in the building. Staff 3 confirmed supervision was not provided to ensure attention to specialized needs such as wandering from the premises. Plan: The administrator or designee will review with direct care staff where to locate new resident information prior to the start of shift.

August 28, 2025Complaint survey1 violation

Inspection dates

08/28/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION

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: 08/28/2025, 11:45 a.m. to 1:00 p.m. 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 08/18/2025 regarding allegations in the area(s) of : Direct Care and Related Services, Administration and Administrative Services, and Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 2 Observations by licensing inspector: Activities Additional Comments/Discussion: None 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on record review and interview with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident

Evidence

On August 18, 2025, at approximately 4:07 p.m., Staff 1 submitted an incident report via email to the licensing inspector regarding a potential environmental issue that occurred on August 15, 2025, involving suspected mold detected in the HVAC units of six occupied resident rooms.
On 08/28/2025, in an interview with the LI, staff 1 confirmed the incident report was emailed on 08/18/2025, although the incident occurred on 08/15/2025.
Photos evidence taken.

Plan of correction

1.The administrator or designee will e-mail the Licensing Inspector when an incident occurs that threatens the resident’s health, safety, or welfare within 24 hours and verify if a report is warranted.

August 28, 2025Complaint survey0 violations

Inspection dates

08/28/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 Complaint InvestigationNone

Technical assistance

Visitor policies and resident's rights to choose visitors, if not deemed legally incapable/incompetent to make decisions.

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: 08/28/2025, 11:00 a.m. to 11:45 a.m. 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 08/18/2025 regarding allegations in the area(s) of: Direct Care and Related Services and Administration and Administrative Services. Number of residents present at the facility at the beginning of the inspection: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 Observations by licensing inspector: Activities Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 11, 2025Inspection1 violation

Inspection dates

07/11/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

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: 07/11/2025, 10:45 a.m. to 4:20 p.m. 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: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Activities and movie and popcorn Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) 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

22VAC40-73-530-C

Based on direct observation and staff interview, the facility failed to ensure that residents were not locked out of their rooms.

Evidence

On 07/11/2025, during the inspection, the licensing inspector (LI) observed six locked resident rooms on hallway one, two, three, and four.
Staff 1 acknowledged that resident rooms were locked.
Photos taken as evidence.

Plan of correction

Community will keep all resident bedrooms unlocked unless the resident falls into the following two categories: 1. Resident is able to locate and unlock their bedroom door without physical assistance from another employee or family member. 2. Resident is unable to ambulate, locate, and unlock their bedroom without physical assistance or supervision from another employee of family member. All residents will be evaluated upon admission. Re-evaluations will be conducted every four months or a change of condition for the listed categories.

July 29, 2024Inspection5 violations

Inspection dates

07/29/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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

22VAC40-73-640-D

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.

22VAC40-73-350-C

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

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.
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.

22VAC40-73-700-1

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

Resident’s 11and 12, had a signed physician order on file for oxygen.
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.

22VAC40-73-700-2

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

Resident 1’s record contained an oxygen order from 10/26/2023, but no oxygen notification sign was posted for the resident’s room.
Resident 11’s record contained an oxygen order from 10/16/2023, but no oxygen notification sign was posted for the resident’s room.
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.

22VAC40-73-450-E

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

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.

September 14, 2023Inspection0 violations

Inspection dates

09/14/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED 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: LI entered the facility at 12:40 pm on 9/13/2023 and exited at 2:05 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: 56 Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed the systems put in place to ensure that resident’s orders are not discontinued unless the facility has an order from the physician. Additional Comments/Discussion: The inspection was conducted to ensure that previous violations that resulted in an intensive plan of correction were corrected. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 25, 2023Inspection0 violations

Inspection dates

07/25/2023

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE

Comments

Type of inspection: Renewal 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 8:44 am on 7/25/2023 and exited at 3:50 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and engaging in activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 5, 2023Inspection0 violations

Inspection dates

07/05/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: LI entered the facility at 10:17 am on 7/5/2023 and exited at 12:17 pm. 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 6/7/2023, 7/3/2023, and 7/4/2023 regarding allegations in the area(s) of resident care and related services and additional requirement for facilities that care for adults with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 58 Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 5, 2023Inspection3 violations

Inspection dates

06/05/2023,07/05/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED 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: LI entered the facility at 12:50 pm on 6/5/2023 and exited at 3:10 pm. LI entered the facility at 10:17 am on 7/5/2023 and exited at 12:20pm. 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 5/30/2023 regarding allegations in the area(s) of administration and administrative services and resident care and related services. 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: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations

22VAC40-73-650-A

Based upon a review of records, the facility failed to ensure that no medications shall be discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over the counter, and sample medications.

Evidence

On 6/25/2023 LI inspected the medication administration records (MARS) for Resident #1. The MARS evidenced that the following medications were stopped: • Amlodipine Besylate 5mg was discontinued on 11/17/2022. • Furosemide 20mg was discontinued on 11/17/2022. • Hiprex Tablet 1gm was discontinued on 11/18/2022. • Omeprazole Tablet 20mg was discontinued on 11/18/2022.
No valid orders from a physician or other prescriber to discontinue the medications were found in the record of Resident #1.

Plan of correction

Intensive Plan of Correction: New, discontinued, or Modified Orders • When Lansdowne Heights receives an order for a medication, the LPN will fax the copy of the order to the pharmacy to input to Point Click Care. The copy will be placed in the Orders Binder with a stamp indicating “Faxed”, dated, and initialed. • For new medications: The LPN will check the Orders Binder daily against Point Click Care and the medications that came from the pharmacy. Once the medications have been received, the LPN will confirm the order in Point Click Care and mark the copy in the binder with a stamp indicating “Complete”, dated, and initialed. • For discontinued medications: The LPN will check the Orders Binder daily against Point Click Care. Once the medication has been discontinued in Point Click Care, the LPN will confirm and mark the copy of the order in the binder with a stamp indicating “Complete”, dated, and initialed. Medication will be removed from the Med Chart and returned to the pharmacy. • For medication modifications: The LPN will check the Orders Binder daily against Point Click Care. If a new dosage for the medication is required, the LPN will follow steps for new medications above. If the frequency was changed, the LPN will confirm the changes in Point Click Care and mark the copy of the order in the binder with a stamp indicating “Complete”, dated, and initialed. • If there are orders that have not been confirmed or medications that have not been received within 24 hours, the LPN will follow up with the pharmacy and document in Progress Notes daily until resolved. • The Director of Personal Care will audit this binder periodically.

22VAC40-73-70-A

Based upon a review of records and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that threatens the life, health, safety, or welfare of any resident.

Evidence

On 5/30/2023 LI received a self-reported incident from Staff #1 documenting that in February 2023, the facility was made aware that medications for Resident #1 had been discontinued in November 2022 and “they should not have been.”
During interview held on 6/12/2023, collateral contact #1 revealed to LI that on 2/16/2023 she reviewed the medication report for Resident #1 and asked the director of personal care “where did mom’s medications go.”

Plan of correction

• The administrator or designee will e-mail the Licensing Inspector when an incident occurs that threatens the resident’s health, safety, or welfare within 24 hours and verify if a report is warranted. • The facility will provide an in-service to LPNs about how to return expired, discontinued, or unused medication to the pharmacy. Community will retain a copy of the medication return receipt in the resident electronic medication record.

22VAC40-73-690-G

Based upon a review of records, the facility failed to document any action that was taken in response to the recommendations noted in the medication review that took place on 12/1/2022.

Evidence

On 6/5/2023 LI conducted a focused monitoring inspection and reviewed the Pharmacy Drug Review. The Pharmacy Drug Review conducted on 12/2/2022 by a licensed health care professional practicing within the scope of his profession evidenced that a recommendation was made to the facility to submit to the pharmacy as soon as possible, a copy of a signed physician’s order sheet for Resident #1, the purpose of which is for the pharmacy to obtain refill authorization easily.
The last signed physician’s order sheet found in the record of Resident #1 was dated 2/2/2022.

Plan of correction

• The facility will write a progress noted within 30 days of receipt of the Pharmacy Drug Review and act in conjunction with the physician for the resident. The progress notes will be a follow-up for each resident that was identified in the report, what the suggestion was, and the recommendation of the physician.

April 28, 2023Complaint survey2 violations

Inspection dates

04/28/2023,05/02/2023

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 10:00am on 4/28/2023 and exited at 12:00pm. LI entered the facility at 2:45 pm on 5/2/2023 and exited at 5:00 pm. 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 4/27/2023 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 59 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: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations

22VAC40-73-70-A

Based upon a review of records and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the health, safety, or welfare of any resident.

Evidence

On 4/28/2023 LI reviewed progress notes for Resident #1. The progress note dated 3/5/2023 documented that Resident #1 had returned to the facility from the hospital at approximately 5:00am on 3/5/2023 and the progress note indicated that Resident #1 was treated at the hospital for “fall and contusion, bruises on multiple part of the body, no head injury, resident alert and oriented to self, no changes in her confused state.”
On 5/9/2023 LI asked the administrator if anyone from the facility had submitted to the LI a report regarding the incident that led to Resident #1 being sent out to the hospital on 3/4/2023. On 5/9/2023 the administrator responded that he was not “100% sure” that anyone submitted a report regarding Resident #1 being sent to the hospital on 3/4/2023.

Plan of correction

The administrator or designee will e-mail the licensing inspector when a resident is sent to the hospital and verify if report is warranted.

22VAC40-73-680-D

Based upon a review of records, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

On 5/2/2023, LI found the following information documented in sampled residents records: a. The physician’s order for Diltiazem CD for Resident #1, written on 8/11/2021, evidenced the following instructions for administration: give 1 capsule by mouth one time a day for hypertension. b. The April 20223 Medication Administration Record (MAR) indicated that Diltiazem was not administered to Resident #1 at approximately 9 am on the following dates: 4/6/2023, 4/8/2023, and 4/18/2023. c. Progress notes written on 4/6/2023 at approximately 9:28 and 4/18/2023 at approximately 9:12 am documented that Resident #1 was not administered Diltiazem for hypertension because hypertension “was not indicated at this time.” Progress note written on 4/8/2023 at approximately 11:02 am documented that Resident #1’s Diltiazem was “not given bp low

Plan of correction

The facility will re-educate the Med Techs and nurses regarding following physician’s orders.

April 28, 2023Complaint survey0 violations

Inspection dates

04/28/2023,05/02/2023

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 building on 4/28/2023 at 10:00 am and exited at 12:00 pm. LI entered the facility at 2:45 pm on 5/2/2023 and exited at 5:00 pm. 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 4/20/2023 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 59 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 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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) 479-5247or by email at jamie.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 6, 2023Inspection1 violation

Inspection dates

04/06/2023,04/10/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: LI entered the facility at 11:25 am on 4/6/2023 and exited at 2:05 pm on 4/6/2023. LI entered the facility at 1:10 pm on 4/10/2023 and exited at 2:55 pm on 4/10/2023. 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 3/28/2023 and 4/10/2023 regarding allegations in the area(s) of resident care and related services, buildings and grounds, and additional requirements for facilities that care for adults with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed camera footage of incidents that occurred on 3/24/2023 and 4/10/2023. LI observed resident’s rooms, including windows and mechanisms in place to prevent the window from opening wide enough for a resident to crawl through. Additional Comments/Discussion: 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. 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.eddy@dss.virginia.gov

Violations

22VAC40-73-450-D

Based upon a review of records and interviews, the facility failed to ensure that when hospice care is provided, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan.

Evidence

According to an interview LI conducted with the administrator on 4/10/2023, Resident #3 was admitted into hospice services on 2/9/2023. The Individualized Service Plan (ISP) that was reviewed by LI on 4/10/2023 for Resident #3 did not include hospice services.

Plan of correction

The community will review and update all individualized service plans for residents that are receiving hospice care by 4/28/23. Facility and Hospice will review bi-weekly that the established plan of care is added to the residents Individualized Service Plan

March 10, 2023Inspection0 violations

Inspection dates

03/10/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED 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: LI entered the facility at 11:16 am on 3/10/2023 and exited at 12:30 pm on 3/10/2023. 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 12/12/2022 and 2/3/2023 regarding allegations in the area(s) of resident care. Number of residents present at the facility at the beginning of the inspection: 60 Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 12, 2022Inspection0 violations

Inspection dates

12/12/2022,12/22/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED 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: LI entered the facility at 3:00pm on 12/12/2022 and exited at 3:55 pm on12/12/2022. 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 1129/2022 regarding allegations in the area(s) of: resident care and related services. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 15, 2022Complaint survey0 violations

Inspection dates

11/15/2022,12/12/2022

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 on 11/15/2022 at 10:28 am and exited at 11:33 am. LI entered the facility at 3:00 pm on 12/12/2022 and exited at 3:55 pm. 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 11/4/2022 regarding allegations in the area(s) of resident care and related services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed resident’s bedroom and bathroom. LI observed residents in the common area participating in activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 30, 2022Complaint survey0 violations

Inspection dates

09/30/2022

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 11:46 am on 9/30/2022 and exited the facility at 1:20 pm on 9/30/2022. 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 9/8/2022 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 26, 2022Inspection0 violations

Inspection dates

08/26/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED 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: LI entered the facility at 7:44 am on 8/26/2022 and exited the building at 10:50 am on 8/26/2022. 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: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration and documentation. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 26, 2022Inspection3 violations

Inspection dates

07/26/2022

Areas reviewed

Comments

Type of inspection: Renewal 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 8:29 am on 7/26/2022 and exited at 3:00pm. 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: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and engaging in activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) 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 Jamie Eddy, Licensing Inspector at (703) 479-5237 or by email at jamie.eddy@dss.virginia.gov

Violations

22VAC40-73-680-H

Based upon a review of records, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration records (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.

Evidence

No initials were entered on the July 2022 Medication Administration Record (MAR) on 7/8/2022 and 7/13/2022 to document that Resident #4 received the prescribed Lorazepam 0.5mg 1 tablet at approximately 9:00am. The Controlled Drug Record documents that the Lorazepam 0.5mg was administered to Resident #4 at approximately 9am on 7/8/2022 and 7/13/2022.

Plan of correction

Lansdowne Heights will verify that all medication documentation is properly recorded on Medication Administration Record and controlled substance log prior to the end of each shift. Education will be conducted to all appropriate staff on Medical Administration Record/Controlled Substance log documentation periodically. Responsible Position: Director of Personal Care, Licensed Practical Nurse, Medication Aide

22VAC40-73-680-C

Based upon a review of records, the facility failed to ensure that medication shall be administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule.

Evidence

According to the Medication Administration Records (MARS), Resident #3 is to receive Toujeo SoloStar Solution Pen Injector 300units/ML daily at approximately 9:00am. The Location of Administration Report documents the following time of administration of the medication: 1.On 7/5/2022 the medication was administered at approximately 10:45 am
On 7/9/2022 the medication was administered at approximately 14:09 (2:09 pm)
On 7/10/2022 the medication was administered at approximately 10:38am
On 7/14/2022 the medication was administered at approximately 10:27 am
On 7/17/2022, the medication was administered at approximately 10:54 am
On 7/18/2022 the medication was administered at approximately 11:36 am
On 7/21/2022 the medication was administered at approximately 10:45 am. According to the MARS Resident #2 is to receive a Trulicity Solution pen injector 0.75mg/0.5ML at approximately 9:00am on Saturdays. According to the Location of Administration Records, the medication was administered at approximately 11:29 am on 7/9/2022 and at approximately 10:55 am on 7/16/2022.

Plan of correction

Lansdowne Heights and Primary Care Physicians will review medication administration times for all residents. Adjustments will be made on medications that can be moved to less busier times to stagger medication pass so residents receive medications during an appropriate window. This will be completed periodically as new residents move-in and at care plan review. Education will be conducted to all appropriate staff on timely administration. Responsible Position: Director of Personal Care, Licensed Practical Nurse, Medication Aide.

22VAC40-73-640-A

Based upon a review of records, the facility failed to implement the medication management plan to ensure medication orders have been accurately transcribed to medication administration records (MARS) within 24 hours of receipt of a new order or change in an order.

Evidence

According to the physician’s order written on 7/12/2022 for Resident #2, the resident was to receive Donepezil 5mg, 2 tablets by mouth daily at bedtime. The order was entered on the July MARS as follows: Donepezil Give 5mg by mouth at bedtime.

Plan of correction

Lansdowne Heights reviewed medication administration records for resident number two and corrected error for sited resident on July 20, 2022. Going forward, Lansdowne Heights will fax new orders to pharmacy once received by prescribing physician. Pharmacy will enter orders into electronic medical record once received. Lansdowne Heights will verify original orders match the medication administration recorded within 24 hours. Responsible Position: Director of Personal Care, Licensed Practical Nurse

November 4, 2021Inspection0 violations

Inspection dates

11/04/2021

Areas reviewed

22VAC40-73 BUILDING AND GROUNDS

Comments

A non-mandated monitoring inspection was initiated on 11/4/2021 and concluded on 11/4/2021. The non-mandated monitoring inspection was initiated to ensure correction of B-2 violations cited during the previous inspection. 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 licensing inspector conducted an on-site observation at the facility on 11/4/2021. The evidence gathered during the investigation did not support any non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 4, 2021Inspection3 violations

Inspection dates

10/04/2021

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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

22VAC40-73-870-E

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.

22VAC40-73-40-A

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.

22VAC40-73-460-D

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.

September 30, 2021Complaint survey0 violations

Inspection dates

09/30/2021,11/09/2021

Areas reviewed

None

Comments

A non-mandated self-report/complaint inspection was initiated on 9/30/2021 and concluded on 11/9/2021. A self-reported incident was received by the department and then a complaint was received by the department regarding the same self-reported incident but with additional concerns, regarding allegations in the areas of resident care. 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 did not support the allegations/self-report of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 4, 2021Inspection2 violations

Inspection dates

Aug. 4, 2021 and Aug. 11, 2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

A renewal inspection was initiated on 8/4/2021 and concluded on 8/11/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 30. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, activities calendar, menu, staff work schedule, fire drill reports, and the annual health and fire inspection reports submitted by the facility to ensure documentation was complete Criminal Background Checks of all staff hired since the previous mandated inspection conducted on 8/11/2020 were reviewed. The inspector conducted the on-site portion of the inspection on 8/6/2021. An exit interview was conducted with the Director of Personal Care and the Business Office Manager on 8/11/2021 where findings were reviewed and an opportunity was given for questions, as well as for providing any information which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations

22VAC40-73-640-A

Based upon a review of records and interview, the facility failed to implement the written plan for medication management to ensure the effective use of MARS (Medication Administration Records) for documentation.

Evidence

Documentation obtained from the facility confirmed that Resident #1 was out of the building during the time that 12:30pm, 13:00 (1pm), and 14:00 (2pm) medications were to be administered on 7/11/2021 and 7/13/2021. The Medication Administration Record (MAR) did not indicate that on 7/11/2021 and 7/13/2021 Resident #1 was out of the facility and not administered regularly scheduled medications at 12:30pm, 13:00 (1pm), and 14:00 (2pm). Progress notes for 7/11/2021 and 7/13/2021 stated that Resident #2 did receive the regularly scheduled Ensure Supplement. The MAR did not record that on 7/11/2021 and 7/13/2021 at 1300 hours (1pm) Resident #2 was administered the Ensure Supplement.

Plan of correction

Staff members that pass medications (RN, LPN, and RMA) will be trained by 9/30/2021 on Medication Administration Record (MAR) documentation for residents that are not available for scheduled medication administration. Director of Personal Care, Care Manager, or Administrator will measure progress and compliance by completing Electronic Medication Administration Record (EMAR) reviews regularly.

22VAC40-73-680-H

Based upon a review of documentation and interview the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.

Evidence

Resident #3 has an physician’s order, dated 07/07/2021, to receive Novolog 100unit/mL 2 units injected subcutaneously before meals. The dosage times listed on the Medication Administration Record are 0700 am; 11:30 am, and 16:30 pm (4:30pm). According to the Location of Administration Report, that is part of the MARS, the dosage time and time of administration for the following dates listed below, would indicate that the medication was either not administered on time or that documentation was entered late. 7/9/2021 11:30am dosage administered at 14:29 7/9/2021 16:30 dosage administered at 18:03 7/11/2021 16:30 dosage administered at 19:08 7/12/2021 11:30 am dosage administered at 13:17 7/12/2021 16:30 dosage administered at 21:33 7/13/2021 11:30 am dosage administered at 19:26 7/13/2021 16:30 dosage administered at 19:26 7/14/2021 11:30 am dosage administered at 15:16 7/15/2021 16:30 dosage administered at 18:10 7/16/2021 16:30 dosage administered at 20:31 7/18/2021 16:30 dosage administered at 20:27 7/19/2021 16:30 dosage administered at 18:31 7/20/2021 11:30 am dosage administered at 14:22 7/21/2021 11:30 am dosage administered at 14:55 7/21/2021 16:30 dosage administered at 21:22 7/22/2021 11:30 am dosage administered at 14::35 7/25/2021 7:00 am dosage administered at 10:33 am 7/25/2021 16:30 dosage administered at 18:36 7/29/2021 16:30 dosage administered at 18:13 7/30/2021 16:30 dosage administered at 18:42 7/31/2021 16:30 dosage administered at 20:39 Interview with staff #3 revealed that this staff spoke with each staff responsible for administering the medication on the dates listed, and all staff reported that the medication was administered on time but that the documentation was done at a later time. The administered time listed on the Location of Administration Report, according to staff #3 is actually the time the staff documented the administration of the medication. Evidence: (RN LPN RMA) ill b t d b 9/30/2021

Plan of correction

Staff members that pass medications (RN, LPN, RMA) will be trained by 9/30/2021 on how to complete Medication Administration Record (MAR) documentation for medication and supplement administration at the time of administration and how to note if medication was not administered within the timeframe prescribed. Director of Personal Care, Care Manager, or Administrator will measure progress and compliance by completing Electronic Medication Record (EMAR) reviews regularly.

August 4, 2021Complaint survey0 violations

Inspection dates

Aug. 4, 2021 and Aug. 19, 2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated complaint inspection was initiated on 8/4/2021 and concluded on 8/19/2021. A complaint was received by the department regarding allegations in the area of resident care. 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 licensing inspector conducted an on- site observation at the facility on 8/6/2021. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.