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: July 24, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 07/24/2023 9:00AM until 3:55PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: noon-time medication passes, audit of multiple medication carts, and observed the noon-time meal An exit meeting will be conducted to review the inspection findings. 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 #:	22VAC40-73-1020-A
Description:	Based on document review and staff interview, the facility failed to ensure that when residents are present there are at least two direct care staff members awake and on duty at all times in each building who are responsible for the care and supervision of the residents when the facility serves a mixed population of residents. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 4 indicates that the resident is disoriented some spheres, some of the time to place, time and situation, the report of resident physical examination for the resident, dated 08/25/2022, indicates that the resident is non-ambulatory by reason of physical or mental impairment and is not capable of self-preservation without the assistance of another person, and the individualized service plan (ISP) for the resident, dated 09/15/2022, indicates that the resident requires two staff members to assisted with activities of daily living care for safety. 2. Interview with staff person 3 and staff person 4 confirmed during on-site inspection on 07/24/2023 that the assisted living section of the building contains a mixed population of residents which means that at least two direct care staff members are to be awake and on duty at all times in the assisted living section of the building. 3. The daily staffing sheets for July 2023 provided by staff person 3 during on-site inspection includes documentation for multiple days on the night shift (11:00PM through 7:00AM) during July 2023 that the assisted living section of the building only had one direct care staff person on duty who was responsible for the care and supervision of the residents. Interview with staff 3 confirmed that the daily staffing sheets contain accurate information.
Plan of Correction:	The Administrator will ensure that the assisted living section of the building, which contains a mixed population of residents, has at least two direct care staff members awake and on duty at all times.
Standard #:	22VAC40-73-1130-A
Description:	Based on observations of the facility special care unit, the facility failed to ensure that when 20 or fewer residents are present in the safe secure unit that at least two direct care staff members were awake and on duty at all times in the special care unit. EVIDENCE: At approximately 9:52AM on the day of inspection, two licensing inspectors (LI?s) noted that staff person 1, who was providing ADL care to a resident in their room, was the only direct care staff person on the facility?s special care unit. Staff person 1 expressed that staff person 2 had left the unit to take trash out to the facility dumpsters.
Plan of Correction:	The Administrator will ensure that when 20 or fewer residents are present in the safe secure unit that at least two direct care staff members were awake and on duty at all times in the special care unit.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that resident physical examinations contained a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H. EVIDENCE: 1. The physical examination, dated 08/25/2022, in the record for resident 4 has documentation on page 2 of the examination that the resident requires continuous licensed nursing care, which is a prohibited condition for admission or retention in an assisted living facility.
Plan of Correction:	The Administrator will ensure that resident physical examinations do not contain a statement that the individual has any of the conditions or care needs prohibited by 22VAC40-73-310 H.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) included all required components. EVIDENCE: 1. The record for resident 1 has documentation of a fall risk rating completed on 06/06/2023 that indicates that the resident is at risk for falls. The ISP, dated 06/08/2023, in the record for resident 1 does not address this identified need. 2. The ISP for resident 2, dated 4/22/2023, indicates that the resident has a need for physical therapy services to ?assist in strengthen and exercising lower extremities gait, balance, and strengthening.? Interview with staff person 3 revealed that resident 2 was not receiving physical therapy services and it was an oversight on the facility to have addressed the need on the ISP. 3. The ISP for resident 3, dated 06/08/2023, indicates that the resident is receiving hospice services through Collateral 3; however, documentation in the record for resident 3 indicates that the resident is receiving hospice services through Collateral 4. Interview with staff person 3 confirmed that the resident is receiving hospice services through Collateral 4. The record for resident 3 includes a fall risk screening form, dated 06/05/2023, that the resident is at risk for falls due to the total score being 10. The ISP for resident 3, dated 06/08/2023, does not include that the resident is at risk for falls. 4. A physician order sheet, dated 05/23/2023, in the record for resident 4 contains documentation that the resident is on a mechanical soft diet. The ISP, dated 04/17/2023, in the record for resident 4 is inconsistent as it has documentation that the resident is receiving a regular diet. 5. The ISP for resident 5, dated 05/18/2023, indicates that the resident has a need for physical therapy services to ?assist in strengthen and exercising lower extremities gait, balance, and strengthening.? Documentation provided by and interview with staff person 3 revealed that the resident is not receiving physical therapy services.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility?s medication carts, the facility failed to follow their medication management plan in regard to ensuring accurate counts of controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management plan contains documentation that ?A narcotic log is completed by off going and on-going RMA?s/LPN and a signature is required by both RMA?s/LPN per shift?. 2. The July 2023 Narcotic Count Key Transfer Sheet for the memory care medication cart does not have staff initials for the off-going or on-coming 11:00PM to 7:00AM shift for numerous dates in July 2023.
Plan of Correction:	The Administrator will update the facility?s medication management plan to reflect new safeguards for maintaining accurate counts of controlled substances whenever assigned medication administration staff changes. The new medication management plan will be adhered to by all RMAs/LPNs.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure that the medications are administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The record for resident 7 contains a physician?s order, dated 7/11/2023, that indicates the resident is prescribed Novolog Mix 70/30 Flexpen, Inject 15U subcutaneously two times a day with breakfast and dinner for DMII, hold for blood sugar less than 100. The July 2023 Medication Administration Record (MAR) indicates that resident 7?s blood sugar at 8:00AM on 07/14/2023 was 96, at 8:00AM on 07/15/2023 was 69, and at 8:00AM on 7/20/2023 was 85. The July 2023 MAR indicates that on the aforementioned dates and times staff administered this medication to resident 7 when the medication should have been held. 2. The 68-hour registered medication aide (RMA) curriculum by the Virginia Board of Nursing (VBON), revised 2022, indicates on page 6 that medication aides may not pour medication for another person to administer and that medication aides may not pre-pour medications for anyone (including self). 3. The licensing inspector (LI) was made aware by staff person 3 via email on 05/11/2023 that on 04/27/2023 at 8:00PM staff person 9, who is an RMA, pre-poured medications for two residents and gave them to staff person 10, who is a nursing assistant, to administer to the two residents. Staff person 3 stated that when staff person 10 went to administer one of the pre-poured medications that staff person 10 was informed was intended for resident 10, resident 10 proceeded to spit out the medication and stated that it was not her medication and that resident 10 was monitored but that the medication was not ingested by the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to ensure that the interior of the building was maintained in good repair. EVIDENCE: 1. Room G-43 was noted to have scuff/scrape marks and drywall damage on several areas of the wall in the room. 2. Room G-63 was noted to have several blinds missing from the window blinds on the window on the room.
Plan of Correction:	The Administrator will ensure that the interior of the building is maintained and in good repair, specifically including repairs to scuff/scrape mark, drywall damage on walls and window blinds.
Standard #:	22VAC40-73-930-A
Description:	Based on observations of the facility?s physical plant, the facility failed to ensure that a signaling device that is easily accessible to residents was available in their bedrooms or in a connecting bathroom that alerts direct care staff that the resident needs assistance. EVIDENCE: Rooms 46, 49, 50, 51, 56 and 63 in the facility?s safe, secure unit did not have a signaling device in the bedroom or adjoining bathroom on the day of inspection. Staff person 3 expressed in an interview that the signaling devices were removed from resident rooms because hourly rounds were being made.
Plan of Correction:	The Administrator will ensure that a signaling device that is easily accessible to residents in their bedrooms or in a connecting bathroom that alerts direct care staff that the resident needs assistance.
Standard #:	22VAC40-73-980-H
Description:	Based on observation and staff interview, the facility failed to ensure there was at least 48 hours of emergency water supply on site. EVIDENCE: On the day of inspection, the facility had 65 residents in care. During an interview with staff person 11, it was determined that the facility only had 24 gallons of emergency water available on site. The Virginia Department of Emergency Management recommends one gallon of water per day for each resident and staff member which would require at least 130 gallons of water on site on the day of inspection for there to be a 48-hour supply.
Plan of Correction:	In regard to 48 hour emergency water supply, the facility will adhere to the Virginia Department of Emergency Management?s recommendation of one gallon of water per day for each resident and staff member on hand. The Administrator will ensure that there is at least two gallons of water on hand for each resident and staff member at all times in order to maintain an adequate 48 hour emergency water supply.