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: Feb. 9, 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

Comments:

ype of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/09/2024 Begin: 11:00am End: 4:14pm 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure a statement that specifies whether the individual is or is not capable of self-administering medication is included on the physical exam which is required within 30 days preceding admission. Residents #1-#5 all are rated dependent in medication administration according to their most recent UAI (Uniform Assessment Instrument) and the ISP (Individualized Service Plan)for all five residents shows medication administration is being offered to all residents as a service. EVIDENCE: 1. Resident #1 was admitted to the facility on 11/28/2023. The physical exam was completed by a physician on 11/16/2023 and did not include a statement of whether resident #1 can self-administer medications. 2. Resident # was admitted to the facility on 11/05/2021. The physical exam was completed by a physician on 11/05/2021 and did not include a statement of whether resident #2 can self-administer medications. 3. Resident # 3 was admitted to the facility on 10/12/2023. The physical exam was completed by a physician on 10/11/2023 and did not include a statement of whether resident #3 can self-administer medications. 4. Resident #4 was admitted to the facility on 08/15/2023. The physical exam was completed by a physician on 08/15/2023 and did not include a statement of whether resident #4 can self-administer medications. 5. Resident #5 was admitted to the facility on 11/01/2023. The physical exam was completed by a physician on 11/01/2023 and did not include a statement of whether resident #5 can self-administer medications.
Plan of Correction:	1-5. The facility will monitor all resident files and be certain that the file will include a statement on the physical form stating whether a resident can administer their own medications. [sic]
Standard #:	22VAC40-73-550-G
Description:	Based on resident and staff record review, the facility failed to maintain evidence that the resident rights were reviewed annually with each resident or legal guardian as well as each staff person and proof of such filed in the resident?s or staff person?s record. EVIDENCE: 1. Resident #2 was admitted to the facility on 11/15/2021. The last signed resident rights was dated 2022. 2. Staff #1 was hired on 02/06/2017. There was not a current (annual) review of resident rights in her employee file. 3. Staff #2 was hired on 12/12/2022. There was not a current annual review of resident rights in her employee file. 4. Staff #3 was hired on 07/19/2010. There was not a current annual review of resident rights in her file.
Plan of Correction:	1. The facility will monitor resident files to ensure resident rights are reviewed at least on an annual basis. 2.-4. The facility will monitor employee files to ensure resident rights are reviewed at least on an annual basis. [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on review of the medication management plan and controlled substance count sheets, the facility failed to include one medication for one resident on the controlled substance counts when medication administration changes. EVIDENCE: 1. Resident #9 is prescribed Gabapentin 100mg, one capsule by mouth three times daily. This medication was mixed in with all other medications and did not have a controlled substance count sheet for this medication.
Plan of Correction:	The facility will monitor counts and count sheets to be positive we are counting all medications that are controlled. [sic]
Standard #:	22VAC40-73-680-K
Description:	Based on the medication cart audit and review of physician?s orders and MARs (Medication Administration Records) the facility failed to have detailed medication orders which include the symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. Residents #5 and #10 both have physician?s orders for Naloxone HCL 4mg Nasal Spray, instill one spray into nostrils every 2-3 minutes as needed for respirator depression. Follow package instructions for emergencies. These orders do not contain all of the above information.
Plan of Correction:	The facility will monitor physicians orders and will make sure all correct information is transcribed on the order. Physician will be aware of this instance in the future. [sic]