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: Oct. 17, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 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: 10/17/2024 from 08:45 AM to 03:30 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 #:	22VAC40-73-1180-B
Description:	Based on observation and staff interview, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: 1. While performing a walk-through of the memory care unit on the date of inspection, LI observed an open door at the end of the hallway within that unit. Upon approaching the open door and looking inside the closet, LI observed an exposed water pipe with knob labeled ?WET SYSTEM? as well as a black box on the wall labeled ?SERIES 800 DETEX ? Integrated Door Security Systems?. The black box also contained a warning that the box has the potential for high voltage and high energy danger and to disconnect the power to the box before servicing. 2. This LI and staff 5 both returned to the memory care unit and observed this open closet with those two potential hazards accessible to residents with a serious cognitive impairment. Staff 5 advised LI that the door is supposed to have a lock on it.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-D
Description:	Based on record review and staff interview, the facility failed to ensure that annual direct care staff training shall consist of the continuing education required by the Virginia Board of Nursing for any registered medication aides. EVIDENCE: 1. The Virginia Board of Nursing website indicates that registered medication aides must annually complete either four hours of population-specific training in medication administration in the assisted living facility in which they are employed, or a refresher course in medication administration offered by an approved program. 2. The record for staff 1, hired 05/30/2017, did not contain evidence that this staff member had completed the annual continued education requirements for a registered medication aide for 2023 and 2024. 3. Interview with staff 5 revealed that there is no documentation to confirm that staff 1 received this annual training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-270-1
Description:	Based on record review and staff interview, the facility failed to ensure that for facilities that accept or have in care residents who are or may be aggressive, direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. EVIDENCE: 1. The facility has a current license which allows for operating a regular assisted living unit and a memory care unit, both of which can house residents with serious cognitive impairments and could possibly display aggressive behaviors. 2. The record for staff 1, hired 05/30/2017, did not contain evidence of having received annual aggressive behavior training. 3. The record for staff 2, hired 04/10/2024, did not contain evidence of having received initial aggressive behavior training. 4. The record for staff 3, hired 06/08/2022, did not contain evidence of having received annual aggressive behavior training. 5. Interview with staff 5 revealed that there is no documentation to support that those three staff members have received any aggressive behavior training either initially or annually.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-480-E
Description:	Based on record review and staff interview, the facility failed to ensure that the physician?s or other prescriber?s orders, services provided, evaluations of progress, and other pertinent information regarding rehabilitative services shall be recorded in the resident?s record. EVIDENCE: 1. The record for resident 4 contained physician?s orders, signed 02/16/2024, indicating that the resident has been receiving wound care services, and the twice weekly service was also confirmed on the resident?s individualized service plan, dated 12/29/2023; however, the resident?s record did not contain any progress notes for the ongoing wound care services. 2. Interview with staff 5 revealed that there are no progress notes in the record for resident 4 and those will have to be requested by the service provider.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-490-A-2
Description:	Based on record review and staff interview, the facility failed to ensure that a licensed healthcare professional who is on-site on a full-time basis, practicing within the scope of his or her profession, shall provide health care oversight at least every six months, or more often if indicated. EVIDENCE: 1. During the on-site renewal inspection on 10/17/2024, LI requested to see evidence that a licensed health care professional has been providing health care oversight at least every six months since the last inspection on 11/02/2023. 2. An interview with staff 5 during the renewal inspection revealed that even though staff 5 is a licensed healthcare professional who is employed by the facility full-time, there is no documentation found that verifies that health care oversight has occurred since the last inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-G
Description:	Based on observation and staff interview, the facility failed to ensure that over-the-counter medication shall remain in the original container, labeled with the resident?s name, or in a pharmacy-issued container, until administered. EVIDENCE: 1. During the on-site renewal inspection on 10/17/2024, LI performed an audit of the 200-hall medication cart with staff 4 present. While inspecting the med cart?s 2nd drawer down, LI observed two over-the-counter (OTC) bottles of medications: ?Sambucol BLACK ELDERBERRY ? ADVANCED IMMUNE SUPPORT with Vitamin C & Zinc? and ?21st CENTURY QUICK DISSOLVE B-12 5000 MCG?; however, neither bottle contained a resident?s name. 2. An interview with staff 4 revealed that she was unable to determine whose OTC medications they were because she could not find any MAR entries where these medications are ordered for administration for any resident(s).
Plan of Correction:	Not available online. Contact Inspector for more information.