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. 17, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 8/17/2020 and concluded on 9/20/2020. A complaint was received by the department regarding allegations in the areas of resident care. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or 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.

Violations:

Standard #:	22VAC40-73-1020-A
Complaint related:	Yes
Description:	Based on a review of resident records, staff schedules and employee interviews, the facility failed to ensure that at least 2 direct care staff members were present at all times in the mixed population areas for the care and supervision of the residents with serious cognitive impairments. EVIDENCE: 1. It was noted that the facility currently has 43 residents residing on the Roanoke and Blackwater hallways. Residents 1 and 2, who live within these areas were noted to have cognitive impairments, which makes it a mixed population within the facility. In a phone interview between the LI and staff person 2 it was determined that only 1 direct care staff member was on duty to work both the Roanoke and Blackwater hallways on the 11 to 7 shift for numerous days throughout July and August 2020.
Plan of Correction:	Facility Administrator/Designee will ensure 2 direct care staff members are present at all times in mixed population areas of facility.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on a review of resident records and staff interviews, the facility failed to report an incident in regards to resident 4. EVIDENCE: 1. The record for resident 4 has documentation of Hospice coming to the facility on 2/29/2020 to assess resident 4 after they sustained a fall and hit their head. The facility failed to submit an incident report to the LI per this standards requirements.
Plan of Correction:	Facility Administrator/Designee will ensure incident report(s) will be submitted to LI per the standard requirements.
Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on a review of the employee work schedule and staff interviews, the facility failed to ensure that staffing was sufficient in numbers to provide services to attain and maintain the physical, mental, and psycho-social well-being of each resident. EVIDENCE: 1. The individualized service plan (ISP) dated 7/15/20 in the record for resident 3 has documentation that the resident requires 2 person assistance with transferring and ADL care for safety. The employee schedule for July and August 2020 has numerous nights where only 2 direct care staff were working the safe, secure unit, where resident 3 resides, which would not allow for staff to be available for other residents care needs if both staff on duty were providing ADL assistance to resident 3.
Plan of Correction:	Staffing will be sufficient to meet the resident needs/services.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to complete a fall risk rating after a resident has fallen. EVIDENCE: 1. The record for resident 4 has documentation in the Hospice notes of resident 4 falling 3 times on 2/29/2020. The record did not contain documentation that a fall risk rating was completed for any of the falls on 2/29/2020.
Plan of Correction:	Administrator/Designee will ensure Fall Risk Rating Tool is completed after fall occurs.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on a review of resident records and staff interviews, the facility to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 4 has documentation that the resident is on a puree diet with nectar thick liquids and is a potential for aspiration. The ISP dated 1/23/20 does not address these identified needs. Also the ISP is inconsistent as it has documentation that the resident is physically and mentally capable of exiting the building but also has documentation that the resident resides on a safe, secure unit and requires 2 hour checks due to cognitive impairments. An interview with staff person 2 expressed that the resident does have cognitive impairment and does reside in the facility locked unit.
Plan of Correction:	ISP corrected to identify resident needs appropriately.