VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Landmark Center
227 Landmark Drive
Stuart, VA 24171
(276) 694-3050

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: July 30, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

A non-mandated self-report inspection was initiated on 7/30/2021 and concluded on 8/26/201. 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 licensing inspector conducted an on-site observation at the facility on 8/17/2021. 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.

Violations:

Standard #:	22VAC40-73-1150-A
Description:	1150-A Based on staff interview, the facility failed to ensure that doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, constant staff oversight, and locking devices. EVIDENCE: 1. An interview with staff 1 indicated that upon further investigation of the 7/30/2021 elopement incident, it was discovered that a door within the memory care unit which enters the ?PT Room? was left unlocked and had no door alarm. In addition, inside the PT Room there is another door which leads to the outside of the building, which was also unlocked. Staff 1 added that the door to enter the PT Room is supposed to be locked, but on the morning of 7/30/2021, the door to the PT Room was unlocked and the other door inside the PT Room was found to be ajar and was sounding an alarm; however, the alarm was unheard by memory care staff because it was sounding behind the closed PT Room door.
Plan of Correction:	Going forward, all door alarms will be checked for proper engagement at every shift change. The exit door inside of the PT Room has been equipped with a stop box. This stop box was installed on Aug 18, 2021. All stop boxes will be checked every shift for proper engagement and signed off on by nurse or med-tech on duty. Camera system has been added to hallways for extra security. Camera monitoring system will be checked periodically by administration, to ensure all rules and regulations are followed. Continuing education will be provided monthly on dementia. Only the lead person will have a copy of the master key after hours. Floor staff must report to lead person to unlock a secured area. All master keys from floor staff have been taken. Med-techs will keys after hours.
Standard #:	22VAC40-73-460-D
Description:	460-D Based on resident record review, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. EVIDENCE: 1. Resident 1 was admitted to the facility?s memory care unit on 7/23/2021. 2. Staff 1 submitted a facility incident report, dated 7/30/2021, which indicated that resident 1 was located in the facility parking lot by a Patrick County deputy on 7/30/2021 around 7:30 AM. The facility incident report stated that no obvious alarms were sounding at the time of elopement. 3. Staff 1 indicated that resident 1 had been placed on 15-minute visual checks starting on 7/29/2021 due to exhibiting wandering behaviors. The 15-minute visual check log for the morning of 7/30/2021 indicated that resident 1 was last seen at 7:15 AM. 4. According to summary notes from the Patrick County Sheriff?s Department, while making morning rounds, the deputy observed resident 1 walking outside of The Landmark Center at 7:35 AM. Resident 1 was identified by his medical alert bracelet. The deputy notified the resident?s POA and returned the resident to The Landmark Center at around 7:50 AM.
Plan of Correction:	Going forward, residents that are admitted to memory care will be placed on 15 minute safety checks for the first 72 hours following admission. Safety checks will continue after the initial 72 hour period, if resident exhibits exit-seeking behavior. All safety check monitoring will be documented on resident ISP, indicating the need for safety checks and the frequency of safety checks. Going forward, all door alarms will be checked for proper engagement at every shift change. Camera system has been added to hallways for extra security. Continuing education will be provided monthly on dementia.