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: Nov. 2, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 11/02/2023 from 08:45 AM until 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 6, with a reassessment date of 04/18/2023, indicates that the resident is assisted living level of care. 2. The record for resident 6 contains nurses notes, dated 05/18/2023 at 05:20 AM, that a CNA reported to an RMA that the resident was found in the floor with blood on his head and that CNA further reported to the CMA [sic] that the resident fell out of bed and a physician?s note, dated 05/18/2023, indicated that the resident was being seen by the physician due to nursing staff reporting that the resident sustained a fall. 3. The most recent fall risk rating in the record for resident 6 is dated 04/11/2023. 4. Interview with staff 6 confirmed that the fall risk rating was not reviewed and updated after the resident?s fall on 05/18/2023.
Plan of Correction:	Director of Nursing or designee (Charge Nurse) to complete assessment of resident and update the fall risk rating assessment annually, after every fall, and as needed (12/31/23). Updated fall process and procedure to be communicated to all appropriate staff (12/31/23)
Standard #:	22VAC40-73-640-A
Description:	Based on record review, policy review, and staff interview, the facility?s medication management plan failed to address its methods to ensure that each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. EVIDENCE: 1. The October 2023 medication administration record (MAR) for resident 1 indicated that the following medications were not administered on the following dates and times due to awaiting pharmacy delivery: VITAMIN D2 1.25 MG (50,000 UNIT) on 10/03/2023 at 08:00 AM and ELIQUIS 5 MG TABLET on 10/18/2023 at 09:00 AM and 08:00 PM. 2. The Medication Management Plan (MMP) provided by the facility on the date of inspection, dated 09/01/2022, states that medications that are to be administered through the facility?s medication administration system are delivered by the pharmacy on a daily basis; however, the MMP does not specify the methods that the facility will use to ensure that prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. 3. An interview with staff 6 also could not verify that the facility?s MMP contained that required component.
Plan of Correction:	Administrator to develop written medication management plan that addresses all necessary components including how the facility will ensure the timely filling and refilling of medications to avoid missing medications. The plan will also address how the facility will handle medications not being available to administer, should the situation arise (12/31/2023). Education to be provided on new medication management plan to all staff who are responsible for medication administration (12/31/2023).