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: May 8, 2024 and May 9, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 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: 05/08/2024 8:45AM until 1:30PM and 05/09/2024 8:15AM until 12:30PM 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 05/01/2024 regarding allegations in the area of: resident care and related services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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:	No
Description:	Based on facility plan review, resident record review and staff interview, the facility failed to ensure to implement its medication management plan regarding methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. EVIDENCE: 1. The facility?s medication management plan, revised 02/2021, states its methods for verifying that medication orders have been accurately transcribed to electronic medication administration records (EMARs) are the following: (a) all new orders are faxed to the pharmacy upon receipt of the order given to facility by a physician; (b) orders are input by pharmacy through EMAR/Eldermark; (c) once the order has been received, input and placed in ?pending review? from pharmacy, the facility will verify the order; (d) a designed registered medication aide, administrator and/or RCC will verify all new medication orders to ensure the required information (name of medication, dosage, frequency, route, diagnosis, stop date, if applicable, certain day/week/month, if applicable) is correct before medication administration is approved; (e) if approved, the medication then becomes part of the residents EMAR and is accessible for administration within 24 hours of receiving the physician order; and (f) if the medication is pending review is not accurate, the pharmacy will be notified to fix the order and the medication will remain in pending review until pharmacy has fixed or only the administrator and/or RCC has access to fix the order in the computer if applicable. 2. The record for resident 1 contains a physician?s order, dated 03/01/2024, for trazodone 50MG take 0.5 tablet (25MG) three times daily every eight hours as needed (PRN) for agitation, yelling, cussing, trying to hit or bite and to contact the physician if the medication is not effective; however, the March 2024 and April 2024 MARs for the resident indicates trazodone 50MG take 0.5 tablet (25MG) three times daily as needed (PRN) for dementia. 3. Interview with staff person 1 confirmed that the physician?s order was not accurately transcribed to the resident?s MAR to include all the components of the order. Staff person 1 confirmed that the facility did not implement its medication management plan regarding ensuring medication orders have been accurately transcribed to MARs.
Plan of Correction:	Plan of Correction: Administrator, Assistant Administrator or RCC will ensure that the indications for a medications administration on the provider?s order accurately and exactly matches the indications that the pharmacy inputs into ?pending review? in EMAR/Eldermark prior to approving the medication to be added to a resident?s EMARand become accessible for administration. Date To Be Corrected: 6/13/2024
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a physician?s order, dated 03/01/2024, for trazodone 50MG take 0.5 tablet (25MG) three times daily as needed (PRN) every eight hours for agitation, yelling, cussing, trying to hit or bite. The April 2024 medication administration record (MAR) for resident 1 contains documentation that the resident was administered trazodone 25MG on 04/07/2024 at 4:31PM and at 8:24PM, on 04/11/2024 at 10:01AM and 1:05PM, and on 04/13/2024 at 1:12PM and 7:54PM. 2. The record for resident 1 contains a physician?s order, dated 04/12/2024, for trazodone 50MG take 0.5 tablet by mouth every night at bedtime; take half tablet to equal 25MG dose for insomnia. The April 2024 MAR for the resident does not contain documentation that the resident was administered the aforementioned medication at bedtime on 04/14/2024.
Plan of Correction:	Plan of Correction: RMAs will be re-educated on the importance of following the EMAR instructions on medication administration per the prescriber?s order. Administrator, Assistant Administrator and RCC will regularly audit EMAR to ensure all medications are being accurately administered in accordance with the prescriber?s instructions. Missed and late medication will be thoroughly audited by Administrator, Assistant Administrator and RCC to ensure that there are no missed or late medications and that all medications are being given in accordance to the prescriber?s instructions. Date To Be Corrected: 6/17/2024