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: March 8, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/08/2024 9:15AM until 10:21AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/01/2024 regarding allegations in the area of: resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: resident care and related services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on observation of facility medication carts and facility policy/plan review, the facility failed to implement their medication management plan regarding ensuring accurate counts of controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management plan states the following: ?A narcotic log is completed by off-going and on-coming RMAs/LPN and a signature is required by both RMAs/LPN per shift.? 2. The narcotic count key transfer sheet for Gills (memory care) contained 5 instances in February 2024 and 2 instances in March 2024 in which the on-coming or off-going RMA/LPN did not sign that they had completed a narcotic count with either the on-coming or off-going RMA/LPN. 3. The narcotic count key transfer sheet for Blackwater/Towers (assisted living) contained one instance in February 2024 in which the out-going RMA/LPN did not sign that they had completed a narcotic count with the on-coming RMA/LPN on 02/29/2024.
Plan of Correction:	The Medication Management Plan was reviewed with all staff RMAs. Education regarding shift change, narcotic counting and the narcotic log was provided to all staff RMAs. All six RMAs who were responsible for the missing signatures on the narcotic logs for February were counseled and received a written disciplinary action. Management will continue to provide support and education to all staff RMAs on the medication management plan, specifically regarding narcotics counting and logging. Management will also be auditing the narcotic logs closely.