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 18, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/18/2024 9:00AM until 9:25AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 04/10/2024 regarding allegations in the area of: resident care and related services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-680-D
Description:	Based on documentation review, resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: The licensing inspector (LI) for the facility received a self-reported incident from staff person 2 on 04/10/2024 that she had been made aware on 04/09/2024 that staff person 1 had administered resident 2?s scheduled, prescribed morning medications to resident 1. The following are the medications that were administered to resident 1: bupropion XL 150MG, centrum tablet, duloxetine DR 30MG, esomeprazole 40MG, gabapentin 300MG, metformin 1,000MG, rosuvastin calcium 40MG, and rybelsus 14MG. Staff person 1 had made staff person 3 aware of the incident and it was verified that resident 1 had received the aforementioned medications. Interview with staff person 2 on 04/18/2024 confirmed that this information is accurate.
Plan of Correction:	Moving forward, the facility will ensure that medications are administered in accordance with the physician?s or other prescriber?s order. Management has counseled and educated the RMA who was responsible for this medication error. The RMA was also pulled from the cart and assigned 2 more days of training prior to being assigned to the medication cart again. All R&P SML RMAs went through a training on 4/23/24. Management will continue to provide education to all existing and new RMAs who may be administering medication to ensure they are administered in accordance to physician order. Regular EMAR audits will be conducted to ensure this.