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. 23, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

The licensing inspector (LI) for Smith Mountain Lake Retirement Village conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 02/23/2022. The LI reviewed special diet orders for four residents, toured the facility's kitchen, and conducted staff and resident interviews relating to allegations of special dietary and medical needs of residents not being met. The information gathered during the investigation supports one allegations of the complaint. Based on the preponderance of evidence the complaint is determined to be valid. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-610-D
Complaint related:	No
Description:	Based on resident record review, staff and resident interviews and observation, the facility failed to ensure that diets prescribed for residents by a physician or other prescriber were prepared and served according to the physician's or other prescriber's orders. EVIDENCE: 1. The record for resident 1 contained a diet order sheet, signed by a physician on 12/22/2021, which stated the resident is to be served a mechanical soft, no concentrated sweets diet. 2. The record for resident 2 contained a diet order sheet, signed by a physician on 01/20/2022, which stated the resident is to be served a mechanical soft diet. 3. The special diet list located in the kitchen during on-site inspection on 02/23/2022 did not include the prescribed special diets for resident 1 and 2. 4. Interview with resident 1 indicated that there are times when he does not receive a plate of mechanical soft food from the kitchen and instead is served a regular plate. 5. Interview with staff regarding resident 2's special diet indicated that there are times when the resident does not receive a plate of mechanical soft food from the kitchen and instead is served a regular plate.
Plan of Correction:	A 100% resident diet audit was completed to ensure diet orders are correct and accurately documented on the resident face sheet and diet order sheet. The special diet list was updated to include a diet order for every resident in the center. Any new admissions will be added to the special diet list in the kitchen. Compliance will be monitored weekly for 1 month then quarterly.