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: April 20, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 BUILDING AND GROUNDS 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 04/20/2021 and concluded on 05/05/2021. A complaint was received by the department regarding allegations in the areas of (standard area). The Administrator was contacted by telephone to conduct the investigation. The licensing inspector requested 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:	No
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 30 residents residing on the AL side of the building. Residents 1 and 2, who live within these areas were noted to have cognitive impairments, which makes it a mixed population within the facility. 2. The facility staff schedule has documentation that only 1 direct care staff member was on duty to work on the AL units on the 11 to 7 shift for numerous days throughout February, March and April 2021.
Plan of Correction:	Facility Administrator/Designee will ensure at least 2 direct care staff will be present at all times in the mixed population areas for the care and supervision of the residents with serious cognitive impairment. During this time of a national pandemic, the facility continues to advertise to hire and retain staff as needed to fulfill the staffing requirements.
Standard #:	22VAC40-73-1130-C
Complaint related:	No
Description:	Based on staff interviews and review of facility employee schedules, the facility failed to ensure that the required number of staff were present during the night hours on the special care unit. EVIDENCE: 1. In a phone interview with staff person 1 on 04/27/2021 it was determined that the facility special care unit has had a resident census between 25 to 27 since February 2021 to current. This census requires a minimum of 3 direct care staff to be on duty at all time in the special care unit. 2. The facility staff schedule has documentation that only 2 direct care staff members were on duty to work on the special care unit on the 11 to 7 (night) shift for numerous days throughout February, March and April 2021.
Plan of Correction:	Facility Administrator/Designee will ensure the required number of direct care staff are present during the night time hours on the special care unit. During this time of a national pandemic, the facility continues to advertise to hire and retain staff as needed to fulfill the staffing requirements.
Standard #:	22VAC40-73-930-B
Complaint related:	No
Description:	Based on interviews with staff and review of facility documentation, the facility failed to ensure that a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal was operable. EVIDENCE: 1. An interview conducted with staff person 1 on 04/27/2021 indicated that the facility's entire signaling device system went down on 01/21/2021. The signaling device was inoperable until 02/16/2021.
Plan of Correction:	If Signaling device becomes inoperable, Facility Administrator/Designee will ensure rounds on every resident is conducted every hour until signaling device is restored.