Landmark Operations Holdings
Families consistently rate this highly — reviewers highlight compassionate and caring staff. Schedule a visit to confirm the fit.
based on 12 Google reviews
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What this means for your family
This facility is highly regarded for its compassionate and devoted staff, which is a significant asset for resident well-being. However, because most reviews are very brief, families should perform an in-person visit to personally evaluate the dining variety and cleanliness.
Google Reviews
Google Reviews
12 reviews on Google“Families can expect a highly caring environment, with multiple reviewers specifically praising the staff's devotion and positive attitude. While the facility has received significant praise for its service during the pandemic, most reviews are brief and do not provide detailed information regarding specific amenities or dining variety.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and caring staff
- High level of devotion to resident safety
- Positive and hardworking team culture
- Good quality food
Rating Trends
Tap a year to see what changed
Distribution · 12 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1It's wonderful to see how much the team values resident safety; could you tell me more about the specific protocols you have in place to ensure everyone stays secure?
- 2The food quality seems to be a real highlight here—could you share what a typical daily menu looks like for the residents?
- 3We noticed the staff is described as very compassionate and devoted; how do you foster that kind of positive team culture within the facility?
- 4For our family member who may need more specialized support, what specific features of your memory care programming help keep residents engaged and active?
- 5Could you walk us through the process for handling medical emergencies or urgent care needs during the overnight hours?
- 6I noticed the management is active in communicating with the community; how do you typically handle feedback or concerns from families to ensure we are all on the same page?
Personalized based on this facility's data
Key Review Excerpts
“The Landmark Center has served our family exceedingly well in recent years. Particularly, the service provided during the pandemic has reflected the staff’s values, caring, and tremendous devotion to their valuable mission.”
“The staff at the Landmark center are wonderful! They really care about their residents!”
“Staff very caring. Food is very good.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Nov 5, 2025Routine
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: 11/05/2025 from 07:30 AM to 03:00 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: 55 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
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. During a walk-through of the facility?s memory care unit on the date of inspection, LI observed two small cups containing an unknown cream-substance on the nightstand in room 411 at 08:20 AM. 2. During the same walk-through of the memory care unit, at the end of the right-side hallway, there was an unlocked closet door and inside there was a plastic container which held numerous bottles of nail polish and nail polish remover at 08:25 AM. 3. The two cups of unknown creams and the container of nail polish bottles and nail polish remover bottles were witnessed by staff 7 who confirmed to LI that they were hazards to the residents of the memory care unit.
Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan ( ISP
Based on record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible party, and that evidence of the review was signed and filed in the resident?s record. EVIDENCE: 1. During the on-site renewal inspection, the record for resident 5 contained a resident rights review, signed by resident 5?s responsible party, on 03/18/2024; however, LI could not locate a 2025 review of resident rights. 2. An interview with staff 5 confirmed that a 2025 resident rights review had not been completed with resident 5 or his responsible party.
Based on observation and staff interview, the facility failed to ensure that a medication storage area/compartment was locked. EVIDENCE: 1. During a walk-through of the facility?s memory care unit on the date of inspection at 07:40 AM, LI observed that the medication-treatment cart was unlocked while sitting in an open office within that unit. Inside of the cart, LI identified numerous tubes of creams and ointments which had been prescribed to residents of the memory care unit. The same cart also contained a pair of scissors and 3 mL syringes with hypodermic safety needles attached. 2. Upon observation, staff 2 was notified and acknowledged that the cart was unlocked and left accessible to residents of the memory care unit.
Based on record review and staff interview, the facility failed to ensure that the medication administration record ( MAR
Nov 5, 2025RoutineCleanReport
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: 11/05/2025 from 07:30 AM to 03:00 PM 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 09/09/2025 regarding allegations in the area(s) of: 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73-(10) 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: 55 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: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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. Use the following last two statements on every Inspection Summary: 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
Nov 5, 2025RoutineCleanReport
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: 11/05/2025 from 07:30 AM to 03:00 PM 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 10/07/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES 22VAC40-73-(10) 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: 55 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Feb 25, 2025RoutineCleanReport
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: 02/25/2025 from 09:30 AM to 01:45 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 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 Holly Copeland, Licensing Inspector at (540)-309-5982 or by email at holly.copeland@dss.virginia.gov
Feb 25, 2025Complaint
Type of inspection: Complaint # 61687 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/25/2025 from 09:30 AM to 01:45 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 02/14/2025 regarding allegations in the area(s) of: Personnel; Resident care and related services; Emergency Preparedness. Number of residents present at the facility at the beginning of the inspection: 59 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: This was a joint inspection with local APS and local law enforcement. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services; Resident care and related services; Emergency Preparedness A violation notice was issued; any violation(s) not related to the complaint(s) 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Based on staff interview, the facility failed to ensure that at all times the department?s representative is afforded reasonable opportunity to inspect all of the facility?s records as specified in ? 63.2-1706 of the Code of Virginia. EVIDENCE: 1. During the on-site complaint investigation on 02/25/2025, LI requested from staff 4 the bath/shower logs for resident 1 for January and February 2025. 2. Staff 4 responded by telling LI that she would have to obtain permission from corporate oversight to see if she could disclose that documentation to LI and requested that a written request be provided through email for that documentation. 3. As a result, on 02/26/2025, LI submitted an email request to staff 4 for the bath/shower logs for resident 1 for January and February 2025. 4. Due to no response, on 03/03/2025, LI submitted another email request to staff 4 for the bath/shower logs for resident 1 for January and February 2025 and training logs/transcripts for staff 1 from 2024 ? 2025. 5. As of the date of this notice, LI has not received the requested documentation from staff 4; however, as part of the complaint investigation, LI was able to obtain the requested bathing/shower documentation for resident 1 from collateral 2.
Based on staff interview and record review, 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: 1. A complaint received by Licensing on 02/14/2025 indicated that about a month prior to the complaint, the facility had heavy smoke and fire that was observed in the corridor that is adjacent to the dining area of the assisted living section of the facility. A staff member had told a visitor that a dryer was on fire and that residents in the area of that corridor were going to have to be moved and 911 was eventually contacted which resulted in an evacuation of residents. 2. During the on-site complaint investigation, LI questioned staff 4 about this incident and it was confirmed that on 12/20/2024, the facility dryer contained oily cloth and started smoking throughout the facility which set the fire alarm off. As a result, the fire department did come to the facility to extinguish the smoke and to air out the facility, but there were no residents or staff injured. 3. During the on-site complaint investigation, collateral 1 informed LI that although there were no injuries, the fire department did have to assist in evacuating the residents until the facility was safe to re-enter during the 12/20/2024 incident. 4. An interview with staff 4 confirmed that this incident was never reported to Licensing.
Based on record review and staff interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including bathing at least twice a week, but more often if needed or desired. EVIDENCE: 1. The Uniform Assessment Instrument ( UAI
Based on record review and staff interview, the facility failed to implement interventions as soon as a nutritional problem is suspected, which include monthly weights to determine whether there has been 5.0% weight loss in one month, 7.5% in three months, or 10% in six months, and notifying the physician if a significant weight loss is identified in any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician?s instructions regarding nutritional care. EVIDENCE: 1. The facility?s WEIGHTS and VITALS SUMMARY report for resident 1 from 12/03/2024 to 03/02/2025 indicates the following instances of weight change: From 08/11/2024 ? 11/12/2024, resident 1?s weight decreased from 120 pounds to 110 pounds, which is just over 7.5% weight loss in 3 months. 2. The record for resident 1 did not contain documentation that the resident was on a physician-approved weight reduction program during that time. 3. The record for resident 1 also did not contain documentation of notification to the resident?s physician of the 7.5% weight loss in that 3-month time period nor was there any documentation where the weight loss was addressed during that time. 4. An interview with staff 3 on the date of investigation revealed that there is no additional documentation outside of the record provided.
Oct 17, 2024Routine
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
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.
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.
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.
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.
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.
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
Sep 24, 2024RoutineCleanReport
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: 09/24/2024 from 01:00 PM until 01:45 PM 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 08/16/2024 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: 52 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: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Feb 22, 2024Routine
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: 02/22/2024 from 09:15 AM until 10:30 AM 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 01/04/2024 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: 57 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A 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-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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Based on record review and staff interview, the facility failed to submit a written report of the incident to the regional licensing office within seven days from the date of the incident. EVIDENCE: 1. On 01/04/2024, LI received an emailed initial (24-hour) self-report from staff 3 which indicated that a medication error occurred at the facility that morning. The report further stated that staff 1 had administered to resident 1 the morning medications that belonged to resident 2 and that the incident was immediately reported to staff 2. The report stated that resident 1 suffered no adverse effects from the medication error and the resident?s physician ordered vital sign checks for every four hours for monitoring. The report also indicated that a full investigation had begun, and the findings will be reported within seven days. 2. As of the date of the on-site follow up, on 02/22/2024, LI had not received the official seven day written report on the medication error and the subsequent findings of the investigation. 3. An interview with staff 2 could not confirm that a written report was submitted to LI, nor the regional licensing office.
Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. On 01/04/2024, LI received an emailed initial (24-hour) self-report from staff 3 which indicated that a medication error occurred at the facility that morning. The report further stated that staff 1 had administered to resident 1 the morning medications that belonged to resident 2 and that the incident was immediately reported to staff 2. The report stated that resident 1 suffered no adverse effects from the medication error and the resident?s physician ordered vital sign checks for every four hours for monitoring. 2. On the date of the follow up investigation (02/22/2024), LI observed that the physician?s orders for resident 1, signed 01/03/2024, and the January 2024 MAR
Based on record review and staff interview, the facility failed to ensure that the medication administration record ( MAR
Based on record review and staff interview, the facility failed to ensure that in the event of an adverse drug reaction or a medication error, the medication administration staff shall document actions taken in the resident?s record. EVIDENCE: 1. On 01/04/2024, LI received an emailed initial (24-hour) self-report from staff 3 which indicated that a medication error occurred at the facility that morning. The report further stated that staff 1 had administered to resident 1 the morning medications that belonged to resident 2 and that the incident was immediately reported to staff 2. The report included that resident 1 suffered no adverse effects from the medication error and the resident?s physician ordered vital sign checks for every four hours for monitoring. 2. An interview with staff 2 also revealed to LI that the resident?s family was notified after the occurrence. Staff 2 added that upon notifying resident 1?s physician of the medication error, it was ordered that resident 1?s own medications be held on the morning of 01/04/2024. 3. Upon a review of the documentation in the record for resident 1, LI was unable to locate documentation of the medication error and the subsequent actions taken by facility staff. 4. An interview with staff 2 revealed that staff failed to document the medication error and subsequent actions taken in the record for resident 1.
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