VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mountain View Retirement Home
2336 Coal Tipple Hollow
Lebanon, VA 24266
(276) 889-3611

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Nov. 18, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Two Licensing Inspectors conducted an unannounced license renewal inspection at Mountain View Retirement Home on 11/18/2019. The inspection began at 9:45 am and concluded at 1:15 pm. A tour of the building and grounds was conducted. Residents and collaterals were interviewed. Resident and staff interactions were observed. Resident and staff files were reviewed. The noon meal and the noon medication pass were observed. Medications and Medication Administration Records were reviewed. The facility was found to have 36 residents in care at the time of the inspection. Required postings and the previous inspection were observed to be in place. An exit meeting was conducted with the administrator on 11/18/2019 and at that time the opportunity was given to find items that were not readily available in the records. As a result of this inspection, nine violations are being cited. A corrective action plan should be developed addressing steps to correct the noncompliance of each standard; measures to prevent the reoccurrence; and person(s) responsible for implementing each step and/or monitoring and prevention measures. The "description of action to be taken" for each violation, along with the "date to be corrected" must be returned to this office signed and dated within 10 calendar days (12/01/2019) of receipt. If you have any questions or concerns, please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on review of staff records, the facility failed to provide verification that a staff person had received a copy of her current job description. EVIDENCE: 1. Staff #4 was hired on 02/03/2019. There was not a copy of her job description available in her staff file.
Plan of Correction:	Job description will be added to employee file and updated. In the future Administator will be cognizant issue. [sic]
Standard #:	22VAC40-73-260-C
Description:	Based on the morning tour of the building, the facility failed to post all staff who have current certification in first aid or CPR so that the information is readily available to all staff at all times. EVIDENCE: 1. The Licensing Inspector did not observe a posting in the building of staff members certified in first aid and CPR. Staff # 5 stated this was not posted.
Plan of Correction:	A posting of current employees with current fist aid/cpr will be added. In the future facility will be more aware of finding and will have current list of valid employees. [sic]
Standard #:	22VAC40-73-290-A
Description:	Based on observations made of the current staff schedule, the facility failed to include an indication of whomever is in charge at any given time. EVIDENCE: 1. The staff schedule dated 11/18-11/22/2019 did not indicate the staff person in charge at any given time. Staff # 5 stated this was not posted on the staff schedule.
Plan of Correction:	This will be added to staff schedule and in the future facility will be more aware that it will be present on all schedules. [sic]
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident's file, the facility failed to have all required information on all resident's physical examination forms. EVIDENCE: 1. Resident # 1 was admitted to the facility on 07/19/2019. Her admission physical was dated 07/17/2019. Allergies were listed as Benadryl and Lovenox, but the description of her reactions were not listed.
Plan of Correction:	Information on document will be added to reflect correct info in the future adm. will be more diligent to this part of the admission process for accuracy from the physicians office. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on review of resident records, the facility failed to address all needs of one resident on the comprehensive Individualized Service Plan (ISP). EVIDENCE: 1. Resident # 2 was admitted to the facility on 07/16/2019. His Uniform Assessment Instrument (UAI) dated 01/02/2019 documents he is disoriented to some spheres some of the time. His ISP dated 07/24/2019 has his cognitive functioning listed as "oriented". This is conflicting information. Staff #5 stated Resident #2 is disoriented to some spheres some of the time.
Plan of Correction:	Information will be correct to document to ensure accuracy. In the future facility will be more cognizant of issue for better accuracy. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during Medication cart audits, the facility failed to ensure medications ordered for PRN (on an as needed basis) are available for administration. EVIDENCE: 1. Resident # 9 is prescribed Calmoseptine Ointment to prevent and help heal skin irritation. This ointment was not available on the medication cart for this resident.
Plan of Correction:	Medication was discontinued. In the future facility will ensure d/c orders are accurate. [sic]
Standard #:	22VAC40-73-710-C
Description:	Based on review of resident records, the facility failed to have a written physician's order that specifies the condition, circumstances, and duration under which the restraint is to be used. EVIDENCE: 1. Resident # 8 had a signed physician's order for restraints dated 05/22/2019 that stated "Bedrails when in bed". This order did not address the specifications of the condition, circumstance, and duration of which the restraint was to be used.
Plan of Correction:	Physician will sign appropriate order forms for restraints. In the future facility will assure accuracy of orders. [sic]
Standard #:	22VAC40-73-925-B
Description:	Based on the morning tour of the building, the facility failed to ensure all common face/handwashing sinks have liquid soap for handwashing. EVIDENCE: 1. In the common bathroom located downstairs across from resident room # B3, the licensing inspector observed the soap dispenser to be empty.
Plan of Correction:	Soap will be added to dispenser. In the future facility will be sure all dispensers have soap. [sic]