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: March 6, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

A complaint was received in the licensing office regarding medication administration and issues with silencing the call bell system by staff and that a part of the call bell system did not work. The complaint was found to be valid. Details can be found in the violations portion of this report. Thank you to staff for your cooperation during this complaint inspection process. If you have additional concerns please call (540) 332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on family and staff interview the call system is silenced on third shift which endangers the health, safety and well being of the residents. The staff also do not always remember to turn the system back on resulting in call bells not being responded to in a timely manner outside of sleep hours.
Plan of Correction:	Residents are checked on through the night and staff felt the call bell was disturbing other residents. They have received training that under no circumstances is the system to be silenced and disciplinary action will follow should it happen again. The administrator assumes responsibility for future monitoring by randomly checking the system at various times during third shift. The date below represents time required to speak with all third shift staff.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Medication was not administered as per scheduled time on 3/2/2020 to a new resident admitted 2/27/2020. The medications were administered two hours beyond the window for administration when error was brought to their attention by family.
Plan of Correction:	Medication in that area was being administered by a medication aide who does not typically work in that area and had not been made aware there was a new resident when she return to work. In the future whenever a new resident arrives for the first two weeks an alert will be noted in the medication record books to ensure that everyone is made aware regardless of their work schedule. The director of nursing assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-930-A
Complaint related:	Yes
Description:	Based on a family report and interview with the administrator, the call system in the building is not operational in the back portion of the building.
Plan of Correction:	The service agency for the call system has been in multiple times and indicate the system the system cannot be repaired and recommend replacement. This will be reviewed with the owner by the administrator to ensure future compliance. Details of replacement will be provided to the licensing office upon receipt. In the interim residents in that portion of the building will be monitored a minimum of every hour with documentation maintained in a log indicating resident name and time of monitoring.