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. 24, 2021

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:

A renewal inspection was initiated on 08/24/2021 and concluded on 08/25/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 63. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, activities calendar, staff schedules, health care and dietician oversight, health and fire inspections and fire drill logs submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 08/25/2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that direct care staff received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff person 4, hired on 05/03/2021, did not contain documentation that this employee has received training in first aid within the first 60 days of employment.
Plan of Correction:	All Direct Care Staff will complete first aid within 60 days of employment.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records, the facility failed to ensure that individualized services plans (ISPs) were updated for a change in resident conditions. EVIDENCE: 1. The record for resident 1 has documentation of a physician order dated 06/08/2021 for wound care to the residents right shin to be completed by Hospice at each visit. The ISP dated 05/26/2021 in the record for resident 1 does not address the identified need for wound care services. 2. The record for resident 2 has documentation of a physician order dated 06/14/2021 for physical therapy evaluation/services to see if the resident would benefit using a walker. Documentation in progress notes for resident 2 dated 06/25/2021 has that therapy is evaluating resident for a rollator walker but that resident 2 is unhappy about it and does not want it. Staff are encouraging resident 2 to use the rollator for his safety. The ISP dated 08/25/2021 in the record for resident 2 does not address the identified need for a rollator walker or the residents refusal to use.
Plan of Correction:	Administrator/Designee will ensure Resident?s ISP clearly reflects resident needs.
Standard #:	22VAC40-73-610-D
Description:	Based on a review of resident records and interviews with staff, the facility failed to ensure that diets prescribed for residents by a physician were prepared and served according to physician orders. EVIDENCE: 1. The record for resident 2 has documentation that the resident is on a no concentrated sweet/no added salt diet. The special diet list in the kitchen did not include the special diet for resident 2. Interviews with staff persons 3 and 6 both expressed that they were not aware of resident 2's special diet orders and that resident 2 was receiving a regular plate from the kitchen.
Plan of Correction:	Administrator/Designee will ensure Resident diets are prepared and served according to physician orders. In-Service will be conducted for all staff.
Standard #:	22VAC40-73-680-E
Description:	Based on a review of medication administration records (MARs), the facility failed to ensure that all treatments or medical procedures were documented on resident MAR's. EVIDEANCE: 1. The record for resident 1 has documentation of a physician order dated 06/08/2021 for wound care to the residents right shin to be completed by Hospice services. The August 2021 MAR for resident 1 does not have documentation of the wound care order. 2. The August 2021 MAR for resident 1 has documentation of physician orders dated 04/13/2021 for a chair alarm when up in wheelchair due to falls. The MAR does not have staff initials for the application of a chair alarm. Per interview with staff person 5, resident 1 is out of bed daily. Documentation dated 05/26/2021 on the ISP for resident 1 has that a bed alarm is used while resident is in bed. The August 2021 MAR for resident 1 does not have documentation of this order. 3. The record for resident 2 has a physician order dated 08/20/2021 for oxygen use for Dyspnea. The August 2021 MAR for resident 2 does not have documentation of this physician order. Observations made during an on-site inspection conducted on 08/25/2021, is was noted that oxygen nor oxygen supplies were available in the facility for resident 2 at the time of inspection.
Plan of Correction:	Administrator/Designee will ensure Resident?s MAR reflects all treatments/medical procedures.
Standard #:	22VAC40-73-700-1
Description:	Based on a review of resident records, the facility failed to ensure that all required information was included in physician orders for oxygen. EVIDENCE: 1. The record for resident 2 has a physician order dated 08/20/2021 for Oxygen 2-4 liters via nasal cannula or mask. The order does not include the oxygen source, when or how often the oxygen should be worn and is not specific with the flow rate to determine what is therapeutic for the resident.
Plan of Correction:	Administrator/Designee will ensure oxygen orders include oxygen source, when or how often to be worn, flow rate deemed appropriate for the resident.
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during an on-site inspections, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. The door to the laundry room that is located on the facility safe, secure unit was observed to be unlocked on the day of inspection. Several cleaning agents (Orange Cleaner, Super-Sorb) were noted in an unlocked cabinet under the sink in the laundry room.
Plan of Correction:	Administrator/Designee will ensure all cleaning supplies and hazardous materials are locked/secure at all times.
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during an on-site inspections, the facility failed to maintain the carpet in the interior of the building in good repair. EVIDENCE: 1. The carpet in the hallway outside of the main dining room heading towards the Craddock Creek unit was noted to be rolling up in several areas on the day of inspection.
Plan of Correction:	Administrator/Designee will ensure the carpet remains in good repair.