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: Feb. 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:

The LI for Smith Mountain Lake Retirement Village conducted an unannounced monitoring visit at the facility on 2/25/2020 from 8:45am until 3:30pm in conjunction with 2 other LI's and noted 74 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. A tour of the physical plant was conducted and the morning medication pass and the mid day meal was observed. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to ensure that all residents personal and social information was obtained prior to admission. EVIDENCE: 1. The personal and social information sheet in the record for resident 3, admitted on 10/26/19 was incomplete as it lacked documentation of the resident current behavioral and social functioning including strengths and weaknesses. 2. The personal/social data sheet in the record for resident 9 was not complete for the section of ?Interests and Hobbies?.
Plan of Correction:	Resident personal and social information will be completed prior to or at time of admission. Administrator/Business Office Manager will ensure completion and kept in resident file. Administrator will review to ensure completion.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI dated 2/18/20 for resident 2 and the UAI dated 2/19/20 for resident 3 were noted to lack the signature of the facility administrator or designee. 2. The UAI for resident 6 has documentation that the resident needs mechanical help and physical human help with dressing. The individualized service plan (ISP) for resident 6 stated that the resident needs physical human assistance with dressing. Interview with staff person 4 revealed that resident 6 only needs physical human assistance with dressing.
Plan of Correction:	Administrator/Designee will ensure the UAI is completed according to the regulation. Routine audit will be conducted for accuracy/completion.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that comprehensive individualized service plans (ISPs) were completed as required. EVIDENCE: 1. The record for resident 1 has documentation from 12/20/19 to current of wound care being provided by a home health agency. The comprehensive ISP dated 12/17/19 does not have documentation of the identified need for home health services. 2. The uniform assessment instrument dated 2/20/20 for resident 3 has documentation that the resident is disoriented to some spheres some of the time with time and situation being the spheres affected. The comprehensive ISP dated 2/20/20 is inconsistent as it has the resident is oriented to all spheres. 3. The record for resident 7 contained occupational and physical therapy notes. The ISP dated 07/18/2019 for resident 7 did not contain documentation of the resident physical and occupational therapy needs. The ISP dated 07/18/2019 for resident 7 also contained two DESCRIPTION OF NEEDS for transferring; ?independent, resident will independently transfer self without assistance? and ?mechanical & supervision, resident will be transferred with supervision assistance and use of mechanical device (grab bars/furniture/wheelchair)?. Interview with staff person 4 revealed that resident 7 is independent in transferring.
Plan of Correction:	Administrator/Designee will preform routine UAI and care plan audits to ensure resident needs are accurately identified and accurate to meet resident needs.
Standard #:	22VAC40-73-620-A
Description:	Based on a review of facility documentation, the facility failed to ensure a oversight of special diet was completed every six months. EVIDENCE: 1. Facility documentation shows the last over sight completed by a dietitian for special diets was completed on 8/15/2019. As of the day of inspection the facility did not have a contracted dietitian to complete special diet over sights.
Plan of Correction:	Administrator/Designee will ensure a Registered Dietician will provide oversight at least every 6 months. Registered Dietician was contacted on day of inspection to complete.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1.The facility?s current medication management plan states a narcotic log is to be 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 hall Blackwater for February 2020 was missing signatures for the following date/time: 02/18/2020; 3-11 outgoing. Multiple dates for outgoing 11-7 and multiple dates for 11-7 oncoming were also missing signatures. 3.The NARCOTIC COUNT/KEY TRANSFER SHEET for hall Roanoke for February 2020 was missing signatures for the following dates/times: 02/14/2020; 7-3 oncoming, 7-3 outgoing, 3-11 oncoming and 3-11 outgoing and 02/18/2020; 3-11 outgoing. Multiple dates for outgoing 11-7 and multiple dates for 11-7 oncoming were also missing signatures. 3. The NARCOTIC COUNT/KEY TRANSFER SHEET for the medication cart in the special care unit had missing signatures for the following dates and shifts: 11pm - 7am outgoing on 2/1/20, 2/2/20, 2/3/20, 2/6/20, 2/12/20 through 2/17/20, 2/20/20 and 2/22/20.
Plan of Correction:	Routine medication cart audits will be performed by Administrator/Designee to ensure medication management plan is followed.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review, the facility failed to ensure that the resident?s record contained the physician?s or other prescriber?s signed written order. EVIDENCE: 1. The medication administration record (MAR) for resident 6 contained medications Levothyroxine 25 MCG effective 02/14/2020 and PreserVision AREDS 2 CHEW and Latanoprost 0.005% effective 02/17/2020. The physicians? orders for these medications were not in resident 6?s chart.
Plan of Correction:	All resident records will contain physician?s orders and will be filed chronologically. Administrator/Designee will ensure orders are filed in resident record.
Standard #:	22VAC40-73-680-B
Description:	Based on medication cart review, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to residents. EVIDENCE: 1. In the medication cart for Roanoke hall, there was a loose round, tan, speckled pill and a small round yellow tablet with ?L? on one side in the third drawer from the top. 2. In the medication cart for Blackwater hall, there was a loose round white pill with a cross score mark on one side and a loose small, round tablet with ?U? on one side and ?25? on the other side located in the second drawer from the top. 3. The medication cart in the special care unit was noted to have two loose pills in the middle drawer and two loose pills in the bottom drawer of the cart.
Plan of Correction:	All medications will be stored in a pharmacy provided container, secured in medication cart. Inservice will be conducted with all registered medication aids and LPNs to ensure medications are property stored and/or disposed of according to medication management plans.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to administer the resident?s medications in accordance with the physician?s order. EVIDENCE: 1. On 02/06/2020, there was a signed physician?s order in the chart for resident 6 ?requesting for medication to be crushed and put in applesauce due to the resident not being able to swallow?. On the day of inspection,the LI observed scheduled 8 AM medications being administered to resident 6 by staff person 2. The medication for resident 6 was not crushed and/or put in applesauce. The individualized service plan (ISP) and medication administration record (MAR) for resident 6 contained no documentation for medications to be crushed and put in applesauce.
Plan of Correction:	All medications will be administered in accordance with physician?s orders. Routine medication cart/Medication Administrator Record audits will be preformed to ensure physician orders are followed.
Standard #:	22VAC40-73-680-I
Description:	Based on medication administration record (MAR) review, the facility failed to ensure that the MAR included all required components. EVIDENCE 1. Medication administration staff initials were missing on MARs for resident 10 for the following medications, dates, and times: Acetaminophen 500mg; 6PM on 2/4/2020, 2/8/2020, 2/10/2020, 2/14/2020, and 2/22/2020, Cyclobenzaprine 5mg; 8PM on 2/14/2020, Furosemide 40mg; 7PM on 2/14/2020, Lorazepam 0.5mg; 9PM on 2/14/2020, Quetiapine Fumarate 50mg; 8PM on 2/14/2020. 2. Medication administration staff initials were missing on MARS for resident 13 for the following medications, dates, and times: Atorvastatin 80mg; 8PM on 2/14/2020, Memantine HCL 10mg; 8PM on 2/14/2020, Quetiapine Fumarate 100mg; 8PM on 2/14/2020, Thick-It Powder; 5PM on 2/22/2020
Plan of Correction:	Residents Medication Administrator Record will contain date, time given and initials of direct care staff administering the medication. Routine audits will be conducted by Administrator/Designee to ensure documentation is present.
Standard #:	22VAC40-73-700-1
Description:	Based on observations made of the facility physical plant, the facility failed to post a "No Smoking-Oxygen in Use" sign in any room of a building where oxygen is in use. EVIDENCE: 1. Room B-35 was noted to contain oxygen tanks and an oxygen concentrator on the day of inspection. The room did not have a "No Smoking-Oxygen in Use" sign posted.
Plan of Correction:	Administrator/Designee will place ?No Smoking/Oxygen In Use Sign? on any room where oxygen is in use. Routine inspection will be completed. Sign placed on resident door at time of inspection. Corrected on day of inspection
Standard #:	22VAC40-73-980-A
Description:	Based on observation, the facility failed to ensure that items with expiration dates must not have dates that have already passed. EVIDENCE: The first aid kit in the special care (memory care) unit contained hand sanitizer that expired in 4/2014.
Plan of Correction:	Routine checks of all first aid kits will be performed by Administrator/Designee and expiration dates will be checked. Expired hand sanitizer removed from kit at time of inspection and replaced.
Standard #:	22VAC40-73-980-H
Description:	Based on observations of the facility physical plant, the facility failed to ensure a 48 hour on site supply of emergency drinking water. EVIDENCE: 1. The facility census on the day of inspection was noted to be 74 residents. Only 36 gallons of emergency drinking water was available on site on the day of inspection.
Plan of Correction:	Administrator/Designee will ensure the facility will maintain 48 hours supply of emergency water on site at any given time. Additional emergency water was ordered on day of inspection. Routine audit will be conducted to ensure water supply is sufficient.