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: Jan. 31, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/31/2023 10:45AM until 12:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. This inspection was conducted as a follow-up to confirm compliance with high-risk violations cited during the 08/11/2022 complaint investigation and the 08/31/2022 mandated renewal inspection and also regarding a self-reported incident provided to the Department on 10/27/2022. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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
Description:	Based on document review and staff interview, the facility failed to implement the section of it?s medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: The facility?s medication management plan, revised February 2021, states that for the facility to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, a narcotic log will be completed by the off-going and the on-coming registered medication aides (RMA)/LPN and a signature is required by both RMAs/LPN per shift. The Department was made aware of a narcotic diversion that occurred at the facility on 10/23/2022. During on-site inspection on 01/31/2023, it was revealed during an interview with staff 1 that staff 2 and 4 signed the narcotic count/key transfer log that they did perform the count and all narcotics were accounted for on 10/23/2022; however, staff 2 and 4 informed staff 1 that they did not perform a narcotic count during the shift change. When staff 5 performed a narcotic count during the morning of 10/24/2022, it was discovered that there was a missing card of narcotics. Interview with staff 1 confirmed that the narcotic diversion by staff 3 had occurred during first shift on 10/23/2022 based on the facility?s video evidence.
Plan of Correction:	Description of Violation: Based on document review and staff interview, the facility failed to implement the section of it's medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: The facility's medication management plan, revised February 2021, states that for the facility to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, a narcotic log will be completed by the off-going and the on-coming registered medication aides (RMA)/LPN and a signature is required by both RMAs/LPN per shift. The Department was made aware of a narcotic diversion that occurred at the facility on 10/23/2022. During on-site inspection on 01/31/2023, it was revealed during an interview with staff 1 that staff 2 and 4 signed the narcotic count/key transfer log that they did perform the count and all narcotics were accounted for on 10/23/2022; however, staff 2 and 4 informed staff 1 that they did not perform a narcotic count during the shift change. When staff 5 performed a narcotic count during the morning of 10/24/2022, it was discovered that there was a missing card of narcotics. Interview with staff 1 confirmed that the narcotic diversion by staff 3 had occurred during first shift on 10/23/2022 based on the facility's video evidence. Plan of Correction: Education provided to all RMAs on Medication Management Policy, specifically in regards to ensuring accurate counts of all controlled substances whenever assigned medication administration staff changes. The Registered Medication Aides involved in failure to appropriately count controlled substances received disciplinary action including write-ups and suspension.
Standard #:	22VAC40-73-660-A-1
Description:	Based on staff interview, the facility failed to ensure that when medications and dietary supplements are administered by the facility, the medicine container that is used for storage was locked. EVIDENCE: The inspector of record for the facility conducted an on-site inspection on 01/31/2023 in regard to a self-reported incident that was received by the Department from staff 1 on 10/27/2022 about a narcotic diversion that occurred at the facility on 10/23/2022. During an interview with staff 1, staff 1 informed the licensing inspector (LI) that staff 2 had left the Roanoke Hall medication cart unlocked and unattended for a period of time during first shift on 10/23/2022. During the time that staff 2 was away from the aforementioned medication cart, staff 3 was able to obtain a card of narcotics from the unlocked medication cart.
Plan of Correction:	Description of Violation: Based on staff interview, the facility failed to ensure that when medications and dietary supplements are administered by the facility, the medicine container that is used for storage was locked. EVIDENCE: The inspector of record for the facility conducted an on-site inspection on 01/31/2023 in regard to a self-reported incident that was received by the Department from staff 1 on 10/27/2022 about a narcotic diversion that occurred at the facility on 10/23/2022. During an interview with staff 1, staff 1 informed the licensing inspector (LI) that staff 2 had left the Roanoke Hall medication cart unlocked and unattended for a period of time during first shift on 10/23/2022. During the time that staff 2 was away from the aforementioned medication cart, staff 3 was able to obtain a card of narcotics from the unlocked medication cart. Plan of Correction: Education provided to all RMAs on Medication Management Policy, specifically in regards to locking the medication cart at all times when not actively standing at cart and using it. Disciplinary action in the form of write-ups and suspension were given to those employees who failed to ensure the medication cart was appropriately locked.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure medications were 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 08/31/2022, for Humalog insulin; check and record fasting blood sugar before meals and at bedtime, inject sliding scale insulin (SSI) as followings: 110-150= 4 units (U), 151-200=8U, 201-250=10U, 251-300=12U, 301-350=14U, above 350 call doctor. 2. The November 2022 medication administration record (MAR) for the resident contains the following documentation: on 11/01/2022 at 11:30AM the resident?s blood sugar was 165 and the resident was administered 4 units of insulin when the resident should have received 8 units; on 11/04/2022 at 4:30PM the resident?s blood sugar was 207 and the resident was administered 8 units of insulin when the resident should have received 10 units; on 11/23/2022 at 11:30AM the resident?s blood sugar was 258 and the resident was administered 10 units of insulin when the resident should have received 12 units and on 11/18/2022 at 4:30PM the resident?s blood sugar was 215 and the resident was administered 8 units of insulin when the resident should have received 10 units.
Plan of Correction:	Description of Violation: Based on resident record review, the facility failed to ensure medications were 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 08/31/2022, for Humalog insulin; check and record fasting blood sugar before meals and at bedtime, inject sliding scale insulin (551) as followings: 110-150= 4 units (U), 151- 200=8U, 201-250=10U, 251-300=12U, 301-350=14U, above 350 call doctor. 2. The November 2022 medication administration record (MAR) for the resident contains the following documentation: on 11/01/2022 at 11:30AM the resident's blood sugar was 165 and the resident was administered 4 units of insulin when the resident should have received 8 units; on 11/04/2022 at 4:30PM the resident's blood sugar was 207 and the resident was administered 8 units of insulin when the resident should have received 10 units; on 11/23/2022 at 11:30AM the resident's blood sugar was 258 and the resident was administered 10 units of insulin when the resident should have received 12 units and on 11/18/2022 at 4:30PM the resident's blood sugar was 215 and the resident was administered 8 units of insulin when the resident should have received 10 units. Plan of Correction: Education provided to all RMAs on medication management and administration in accordance to prescriber's orders. Special education was devoted to the few sliding scale medications that we administer.