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. 31, 2022

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 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:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 08/31/2022 8:40AM until 3:15PM 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: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: a sample of the morning medication pass, activity in the facility?s safe, secure unit, medication cart audits of all medication carts 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, document review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) contained all required components. EVIDENCE: 1. The individualized service plan (ISP) for resident 2, dated 07/27/2022, indicated that the resident?s food is to be cut up and the special diet posting the facility?s kitchen indicated that the resident?s food is to be cut up as well; however, the resident?s UAI, dated 07/27/2022, does not indicate the resident requires mechanical assistance with eating/feeding. Interview with staff 5 and 6 confirmed the resident requires his food to be cut up. 2. The record for resident 4 included ?Acute Care Visit? documents that stated the following: ?04/11/2022 ? patient is being seen for agitation and aggression?; ?05/09/2022 ? increased mood behaviors during the evening? and ?05/26/2022 ? recurrent aggressive behavior and agitation towards other residents?. The resident?s UAI, dated 03/01/2022, does not include documentation of the resident?s behavior. 3. The UAI dated 04/08/2022 in the record for resident 7 has documentation that the resident has a behavior pattern of wandering/passive weekly or more. The type of inappropriate behavior section on the UAI has documentation of ?N/A? and does not include the resident?s specific behaviors.
Plan of Correction:	The resident's UAI will be corrected to reflect wandering on the unit. UAI updated to reflect resident needs. UAI updated to reflect correct diet.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 7 has a physician order dated 04/07/2022 for a regular, no added salt, low cholesterol, low fat diet. The ISP dated 04/08/2022 in the record for resident 7 does not include the residents special diet needs as it only has that resident 7 is on a regular diet.
Plan of Correction:	Order Clarified to reflect correct diet.
Standard #:	22VAC40-73-640-A
Description:	Based on medication cart audit, resident record review, staff interview and document review, the facility failed to implement their medication management plan. EVIDENCE: 1. The facility?s medication management plan, revised February 2021, states that for the facility to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes a narcotic log will be completed by off-going and on-coming registered medication aides (RMA)/LPN and a signature is required by both RMAs/LPN per shift. The ?Narcotic Count/Key Transfer Sheet? document for halls Gills Creek, Roanoke and Blackwater for August 2022 include multiple days and shifts that staff did not sign that a narcotic count was completed. 2. The record for resident 1 has documentation of a physician?s order dated 08/25/2022 for Eliquis 2.5mg, one tablet in the morning and 1 tablet before bedtime to begin on 08/31/2022. It was noted during the morning medications pass that this medication was not available in the facility for administration. The facility?s medication management plan has documentation that ?New medication orders received from physicians are to be faxed to the pharmacy daily by 4 pm. Refills need to be faxed to pharmacy at least 48 hours in advance. If refill is needed immediately, call and fax the pharmacy with order so delivery can be made as soon as possible?.
Plan of Correction:	Education provided to all RMAs on standard narcotic sign-in/sign-out protocol. Narcotics sheets to be checked upon every shift when report is given.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that all required information was included in physician orders. EVIDENCE: 1. The August 2022 medication administration record (MAR) for resident 5 has documentation of a physician order dated 01/18/2022 for Lispro Insulin (Humalog Kwiwpen 100U/ml) as needed for sliding scale coverage. The order is not clear as is has documentation to give 4 units of insulin if resident 5?s blood sugar is 111 to 151 and to give 8 units of insulin if resident 5?s blood sugar is 151 to 200. It was noted that staff initials are present on 08/04/2022 at 4:30pm for administering 8 units of insulin when resident 5?s blood sugar was 151. Staff initials are also present on 08/13/2022 at 4:30pm for administering 4 units of insulin when resident 5?s blood sugar was 151.
Plan of Correction:	The order was clarified by the Facility Nurse Practitioner of the day of our inspection.
Standard #:	22VAC40-73-660-B
Description:	Based on observations made of the facility physical plant and resident record review, the facility failed to ensure that medications kept in resident rooms are only permitted for residents who are indicated as capable of self-administering their own medications. EVIDENCE: 1. During the morning medication administration pass conducted on 08/31/2022 a tube of Kroger Brand Hydrocortisone 15 cream, a bottle of Tums Smoothies and a bag of Kroger Brand Cough Drops were observed sitting out on a table in room C-71 where residents 3 and 5 reside. The uniform assessment instruments (UAI) both dated 01/17/2022 for residents 3 and 5 have documentation that these resident are both assessed as requiring medication administration from a layperson. An interview with staff 3 indicated that the facility administers medications to both residents 3 and 5.
Plan of Correction:	The items were removed from the resident's room and family was made aware to not continue to being those items in unless we are made aware and an order is obtained.
Standard #:	22VAC40-73-870-A
Description:	Based on a tour of the facility?s physical plant, the facility failed to ensure the interior and exterior of the building was maintained in good repair and kept clean. EVIDENCE: 1. Two licensing inspectors (LIs) observed the locking mechanism of the door located in the facility?s courtyard was broke and therefore the door was unable to be locked. This was also observed by staff 5 during inspection. 2. The carpet leading into the facility?s safe, secure unit contained multiple stains. 3. The dining room located by the courtyard in the facility?s safe, secure unit contained multiple stained areas around the baseboards and quarter round moldings and was sticky to the touch.
Plan of Correction:	A work order had been put in and the broken part had been ordered at the time of inspection. The gate has been repaired. Carpet will be cleaned and free of stain. Baseboards will be cleaned and free of dirt and grime and maintained.