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: Aug. 25, 2020

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 renewal inspection was initiated on 8/25/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 59. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, employee schedules, Fire and Health inspections, fire drill logs, health care and Dietitian oversights submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on a review of staff records, the facility failed to ensure that staff who work in a safe, secure environment received 10 hours of training in cognitive impairments within the first 4 months of employment. EVIDENCE: 1. The record for staff person 1, hired on 3/23/20, has documentation of only 7 hours of training in cognitive impairments within the employees first 4 months of employment. Per a phone interview with staff person 5, this employee worked on the facility safe, secure unit. 2. The record for staff person 4, hired on 1/16/20, has documentation of only 5 hours of training in cognitive impairments within the employees first 4 months of employment. Per a phone interview with staff person 5, this employee worked on the facility safe, secure unit.
Plan of Correction:	Staff Person 1 is no longer employed. Effective 9/1/2020. Staff Person 4 will meet the criteria for training in cognitive impairment by September 4, 2020. Date to be corrected 9/4/2020. Moving forward the Administrator will ensure all staff working the safe/secure unit will meet the criteria for staff training.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required by 22VAC30-110. EVIDENCE: 1. The UAI dated 11/18/2019 in the record for resident 4 has documentation of a reassessment for the residents dressing ADL needs but the UAI does not have documentation of the date of the reassessment or the signature of the person who completed it.
Plan of Correction:	The UAI will be updated to reflect signature and date today.