VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Willow Estates Retirement, Inc.
180 Titus Drive
Penn laird, VA 22846
(540) 908-0723

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Sept. 17, 2019

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 63.2 General Provisions. 63.2 Protection of adults and reporting. 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

Technical Assistance:

1. Agreement and disclosure need additional updates due to change in regulations in 2018; 2. Dietician needs to sign review; 3.Until background checks are on site, staff without one but be maintained in line of sight of a staff who has one on file; 4. With the number of medications administered and number of individuals in facilities electronic medication administration records are recommended; 5. Recommend outside healthcare oversight since two nurses are primary for service plans, assessments and medication; and 6. Based on comments from families and residents a full time activities person would be most beneficial. Census: 58 12pm-5pm

Comments:

Nine violations were identified during this unannounced monitoring inspection. The areas of noncompliance were service plans, annual resident rights, initial and annual tuberculosis testing/screening, medication management and administration, emergency drills, environmental precautions/storage of hazardous materials and water temperatures. Details can be found in the violation portion of this report. The facility was clean and odor free. Residents were clean and dressed appropriately. The meals observed were as per the menu which appeared to meet physician orders. Medication administration issues are outlined in the violations. The facility is required to complete an Intensive PLan of Correction (IPOC) for this area. The facility has a new full time nurse to assist with this process. A music program was observed as the activity. Activities were the primary concern voiced by residents. They were not varied and didn't always occur. There was little physical activity noted on the schedule or outside time for those persons unable to go outside without assistance. Outside inspections were current. Two inspectors participated in this process. Thank you to residents, families, outside providers and staff for your cooperation during this monitoring inspection process. If you have additional questions or concerns please call (540) 332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1070-B
Description:	The facility provides assistance to a mixed population which includes individuals that have a diagnosis of some form of dementia. Based on a walk through of the facility materials that could be harmful were found to be accessible to residents: A. Medication Cart containing treatment supplies was unlocked in the main hallway; B. Prescription and over the counter medication was found in the unlocked cabinets in two of the shared bathrooms; C. Nelson Hall bathroom - appeared to be for storage and was unlocked; D. Restroom across from room 27 contained multiple cleaning supplies; and E. Resident room contained wound care supplies such as disinfectant spray and calmoseptine unlocked on a shelf as you entered room.
Plan of Correction:	Storage areas will be locked. All prescription and over the counter medications will be kept in the med cart of in a lock box in resident room as applicable. Cleaning supplies will be removed and not stored in any bathrooms or other unlocked areas. A different staff person will be assigned weekly to do a walk through of the facility and monitor for these specific things and report to nurse or administrator. Nurse and administrator assume responsibility for correction and future compliance. Issues were immediately addressed and date of correction notes implementation of full monitoring plan as outlined.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff and resident records there was not documentation to demonstrate compliance with ensuring initial tuberculosis screenings for staff prior to resident contact and residents prior to admission or annual screenings of staff and residents.
Plan of Correction:	All records will be reviewed and annual screenings to be completed as required. Screenings will be required prior to staff working on the floor in any capacity and prior to or at the time of admission of residents. The administrator and facility nurse will be responsible for correction, future compliance and continued monitoring..
Standard #:	22VAC40-73-450-C
Description:	Based on a random selection of resident records and review of their individualized service plans the service plans failed to consistently include: Fall Risk (assessments could also not be located in records) Mechanical supports Ability to use call bell system Need for Epi pen - allergic reactions Special diets Residents requiring the assistance of more than one staff person
Plan of Correction:	All service plans will be reviewed to ensure all components are addressed for compliance. Facility nurse will be attending an ISP training to further assist staff in the development of plans. The administrator and nurse assume responsibility for correction and future compliance.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records there was not consistent documentation that all applicable residents had received an annual review of resident rights.
Plan of Correction:	Resident rights will be added at the time of the annual review of the service plan to better ensure review of the rights with the individual. Signature or mark on the service plan will serve as documentation that rights have been reviewed. The administrator and facility nurse assume responsibility for correction for compliance and future monitoring. In the interim rights will be reviewed with all residents and documented to complete immediate compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on a review of a random sample of medication administration records and the facility medication management plan the facility has not updated their plan to include requirements for the regulation changes from 2018. The last review by staff was noted to be 2016. Further the facility failed to follow the plan they have in place as follows: Plan notes medication administration records to be reviewed weekly with documentation - as per staff interviews and inspector review the weekly reviews were not being done; The plan for filling or obtaining prescriptions in a timely manner was not being followed as multiple incidents of "medication not available" for three to five days and up were noted on the medication administration records; Plan was not being followed in regards to storage of medication as noted as part of the environmental hazards violation; and The plan was not readily available to staff administering medication. When interviewed they had no idea where it was or what it was.
Plan of Correction:	The facility has requested a copy of the medication plan prepared by the licensing office to use as a model to update their medication administration plan. The plan will be updated and submitted to the licensing office for their approval. Upon return receipt all medication aides will receive documented training and the plan will be readily available to them. It will be made part of the orientation for new medication aides and also a part of annual training and review. The nurse assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-680-I
Description:	Based on review of a random sample of medication administration records (MARs) the administration of medication was not documented in compliance with the standard as follows: Start dates for orders added to the MAR were not consistently found; Orders did not consistently have a single dose noted but rather a range; Results for the use of PRN/as needed medications were not consistently documented; Reasons for the use of PRN.as needed medications were not consistently documented; Multiple diagnosis/uses for a single medication as opposed to a single usage; Discontinue dates for medication not consistently indicated; Dosage changes were marked through and made on current order instead of discontinuing and rewriting on the MAR; Parameters noted for contacting physician related to blood pressures and blood glucose levels were not followed; Blanks on the MAR for prescribed medication interpreted as medication not given; and Physician order changes in record not noted on the MARs It was also noted that many physician order sheets were not signed by the physician.
Plan of Correction:	Due to the systemic nature of medication administration issues an intensive plan of correction (IPOC) is being requested of the facility. Plan will be due in the licensing office by Oct. 31, 2019.
Standard #:	22VAC40-73-860-G
Description:	Based on random water temperature checks throughout the building, hot water taps were found to exceed 120 degrees Fahrenheit as follows: Room 36 - 129.1 degrees Room 40 - 135 degrees Room 43 - 136.8 degrees This is the same area of the building that problems have been noted regarding water temperatures in the past.
Plan of Correction:	A plumber was contacted and made aware of the issues with the water temperatures in that portion of the building. The hot water heater will be adjusted and staff are to monitor temperatures on a weekly basis and report findings to the administrator for follow-up by the plumber as applicable if temperatures rise again. Considering the repetitive nature of the problem temperature monitoring will be ongoing.
Standard #:	22VAC40-73-970-A
Description:	Based on a review of emergency training records fire drills have not been conducted quarterly on each shift. The documentation available for drills was not complete and did not indicate the year in which they occurred or training received by staff after the fact.
Plan of Correction:	The administrator and nurse assume responsibility for correction and future compliance. Beginning in October a drill will be held each month for a different shift and documented accordingly. Fire plans will also be reviewed during staff meetings.
Standard #:	22VAC40-73-990-C
Description:	Based on review of training files and staff interviews resident emergency drills had not been completed at least every six months as required for compliance.
Plan of Correction:	The nurse will assume responsibility for ensuring that resident emergency drills are conducted at least every six months for all staff and documented accordingly. The first drill will be completed before the end of November. The nurse also assumes responsibility for future compliance.