VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Smith Mountain Lake Retirement Village
115 Retirement Drive
Hardy, VA 24101
(540) 719-1300

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Dec. 20, 2019 and Feb. 25, 2020

Complaint Related: Yes

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

The Piedmont Licensing Office received a complaint in regards medical care and discharge, staff training, visiting hours and signaling device issues in regards to a resident at Smith Mountain Lake Retirement Village. The LI for Smith Mountain Lake Retirement Village conducted an unannounced complaint investigation at the facility on 12/20/2019 from 9:30am until 12:30pm in conjunction with 2 other LI's. A follow up visit on 2/25/2020 from 9am until 1pm was also conducted with 2 other LI's. The medical record for resident 1 was reviewed and medical records from hospitalizations/ER visits from 12/2018 through 2/2020 was obtained. Staff records and training were reviewed and interviews were conducted with numerous staff. A tour of the physical plant was conducted and the facility signaling device was observed. Facility menus, activity schedules, policy and procedures, resident handbook and resident council meetings were reviewed. Based on all information available for review 2 areas of the complaint were founded and violations were cited. Please respond back to your LI with a plan of correction. If you have any questions please feel free to contact your LI.

Violations:

Standard #:	22VAC40-73-580-F
Complaint related:	Yes
Description:	Based on a review of resident 1's record, the facility failed to notify the attending physician when a significant weight loss was identified. EVIDENCE: 1. The record for resident 1, admitted to the facility on 12/6/2018 has documentation of a weight of 122 lb in December 2018. The record shows a 9 pound (7.5%) weight loss in 3 months (108 lb in March 2019) and a 22 lb ( greater than 10%) weight loss in 6 months (100 lb in June 2019). The record does not have documentation that resident 1's physician was made aware of the significant weight loss or of obtaining any physician orders regarding nutritional care.
Plan of Correction:	Significant weight loss will be reported to MD/FNP. Admin/designee will report.
Standard #:	22VAC40-73-740-D
Complaint related:	Yes
Description:	Based on observations and staff interviews, the facility failed to implement their written policy regarding missing personal possessions. EVIDENCE: 1. Documentation was received that a personal camera was removed from resident 1's room by facility staff. Interviews with staff expressed that a small "nanny cam" type device was removed from resident 1's room and placed on the units medication cart. When staff went back to retrieve the device it was unable to be located. The facility failed to follow their missing items policy in regards to documenting the missing items, completing incident reports, placing information on appropriate lost/found sheet and maintaining contact with responsible party in regards to updates to the search for missing items.
Plan of Correction:	Administrator and/or business office manager will ensure missing items P/P is followed.