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: Aug. 3, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 8/03/2020 and concluded on 9/23/2020. The complaint was received by the department regarding allegations in the area of infection control. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed and phoned the administrator to request documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards of law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. As a result of this inspection four violations are being cited. If you have any questions please feel free to contact your licensing inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-100-F
Complaint related:	No
Description:	Based on interviews with staff and medical professionals, the facility failed to follow the recommendations made by the Virginia Department of Health to prevent or control the transmission of an infectious agent in the facility. 1. On 6/19/2020, the Virginia Department of Health released strategies for Personal Protective Equipment (PPE) in Long-Term Care Facilities. These recommendations include all healthcare personnel wear a mask while in the facility. It further states all healthcare personnel must wear a gown and eye protection in addition to the facemask and gloves when performing activities such as dressing, showering/bathing, transferring, assisting with hygiene, changing linens, and changing briefs or assisting with toileting. This document also states that all residents should wear a face mask all of the time and practice good hand hygiene. 2. Licensing Inspector spoke to 13 staff members; all reported that PPE was available to them from the onset of COVID-19 in/around March 2020. 3. During staff interviews with the 13 staff members between 8/03/2020-8/06/2020, Staff #s 2, 3, 5-7, and 9-13 stated that prior to the first resident tested positive for COVID-19 (7/30/2020) some staff wore PPE; which only included gloves and masks, and some did not. The staff that stated they wore masks stated they did not wear them during their entire shift because they were hot and uncomfortable to work in. Staff#15 stated she was only wearing gloves. And Staff # 4 stated she wore a mask out in the community, but not while at the facility working because it was too hot and she has a breathing condition diagnosed by a medical professional. 4. All 13 staff stated that after the first COVID-19 positive case within the facility on 7/30/2020 all staff started wearing face masks, gloves, gowns, feet coverings, and face shields. 5. On 8/2/2020, Medical Professional #1 spoke to Staff #1 and followed up with an email regarding the recommendations that were made by the Virginia Department of Health to control the spread of COVID-19. 6. On 8/03/2020, Medical Professionals #1 and #2 stated they had visited the facility on 8/02/2020, where approximately ten residents were observed to be lingering in a common area of the facility. None of the ten residents were observed to be wearing masks. Seven of these ten residents had tested positive for COVID-19. 7. An employee working during the time Medical Professionals #1 and #2 were present was observed to be wearing a mask, but had it pulled down under her nose. This is not the proper way to wear a mask to prevent or control the transmission of COVID-19. 8. During a phone conversation with Medical Professional #1 on 8/3/2020, it was reported that a staff member told Medical Professional #1 on 8/2/2020 that one COVID-19 negative resident was still placed in the same room as a COVID-19 positive resident. 9. Medical Professional #1 reports on 8/13/2020 that a COVID-19 positive staff was working.This staff had been working with symptoms for approximately one week and stated, ?I just know I?m going to be positive? when she was tested. 10. Licensing Inspector spoke with Staff #1 on 8/14/2020 and was told that no positive and negative residents were rooming together at this time and stated that they had all been separated but did state that ?every now and then there is one that we will catch wandering down the hallway?. 11. On 8/28/2020 Medical Professional #1 stated that the Health Department would no longer go to the facility and do testing since it has decreased. It was recommended by the Virginia Department of Health to Staff #1 that an outside source come into the facility to test the few residents that were still negative for COVID-19. 12. As of 9/22/2020, Staff #2 stated that there had not been an outside source to come to the facility for any additional, but would follow up.
Plan of Correction:	The provider's response for the plan of correction was not receievd by 11-20-2020 and will not appear on this violation notice.
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on interviews with staff and medical professionals as well as review of documentation from facility staff, the facility has failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, safety, or welfare of any resident. EVIDENCE: 1. Residents #1 and #2 were admitted to the hospital on 8/9/2020. 2. Resident #3 was admitted to the hospital on 8/10/2020. 3. Resident #4 was admitted to the hospital on 8/27/2020. 4. Resident #5 was admitted to the hospital on 8/24/2020. 5. Resident #6 was admitted to the hospital on 8/19/2020. 6. Resident #7 was admitted to the hospital on 9/17/2020. This resident expired on 9/21/2020 at the hospital. She was not receiving Hospice services at her time of death. 7. Resident #8 was admitted to the hospital on 7/29/2020. This resident expired on 9/15/2020 at the facility where she was receiving Hospice services. 8. Resident #9 was admitted to the hospital on 8/25/2020. This resident expired on 9/04/2020 in the hospital where she was receiving Hospice services. 9. Resident #10 expired on 08/13/2020 at the facility; this resident was not receiving Hospice services at the time of death and she was never hospitalized. This information was shared only when the Licensing Inspector called the facility on 8/13/2020 to check for any additional updates. 10. Resident #11 was admitted to the hospital on 7/30/2020. This resident expired on 8/30/2020 in the hospital where she was not receiving Hospice services. 11. All 11 residents tested positive for COVID-19, ten of the 11 residents were hospitalized. Five of the 11 residents that tested positive expired at the facility or in the hospital as a result from COVID-19 complications. 12. None of these 11 incidents involving 11 different residents were reported to the regional licensing office within 24 hours.
Plan of Correction:	The provider's response for the plan of correction was not receievd by 11-20-2020 and will not appear on this violation notice.
Standard #:	22VAC40-73-70-C
Complaint related:	No
Description:	Based on interviews with staff and medical professionals, the facility failed to submit a written incident report to the regional licensing office within seven days when 11 residents were hospitalize and or expired. Three of the 11 residents expired while not receiving Hospice services. The report should be dated and signed by the administrator and include all information required by the standard. 1. Residents #1- #11 were all admitted to the hospital and/or expired between the dates of 7/29/2020-9/21/2020. All 11 residents had previously tested positive to COVID-19. 2. There were no written reports sent to the regional licensing office for any of the residents.
Plan of Correction:	The provider's response for the plan of correction was not receievd by 11-20-2020 and will not appear on this violation notice.
Standard #:	22VAC40-73-300-A
Complaint related:	No
Description:	Based on a telephone interview with staff at the facility, the facility failed to establish and follow a procedure of communication among staff to ensure stable operations and sounds transitions; this shall include designated staff persons in charge. EVIDENCE: 1. On 8/28/2020 when Licensing Inspector (LI) called the facility, Staff #12 answered the phone during evening shift. Licensing Inspector was calling to get an update of how things were progressing at the facility with COVID-19 testing and numbers. LI asked Staff #12 who was in charge, she was confused and sated ?I guess I am?. LI asked if the health department had completed another round of testing at the facility on the negative residents and asked the current number of COVID-19 positive cases within the facility. Staff #12 stated they had tested at the facility last week, and she was not sure of the results and did not have knowledge of the number of positive COVID-19 cases that were currently in the facility. Staff #12 further stated that she normally worked night shift and she really did not know what was going on.
Plan of Correction:	The provider's response for the plan of correction was not receievd by 11-20-2020 and will not appear on this violation notice.