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: July 27, 2020 and July 30, 2020

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 EMERGENCY PREPAREDNESS 63.2 Protection of adults and reporting. 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. Facility has new nurse and concerns regarding medication administration records (MARs) were reviewed with her. 2. Background checks were addressed by the facility owner. 3. Facility continues to maintain no direct contact visitation at this time. 4. Licensing will be notified when background checks are completed.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated July 27, 2020 and concluded 8/10/2020. The administrator was contacted by email to initiate the inspection. The administrator reported that the current census was 52. Based on the census, the inspector faxed the administrator a list of items required to complete the inspection. The inspector reviewed 4 staff records and background checks for staff hired since the previous inspection, 4 resident records plus additional medication records based on diagnosis, staff schedules, fire and health inspections, and health care and dietary over site submitted by the facility to ensure documentation was complete.Training records were reviewed as applicable along with fire and emergency drills. Information gathered during the inspection determined non-compliance with applicable standards or law in two areas. Violations were documented and reviewed with the administrator and can be found on the violation notice issued to the facility. Thank you to facility staff for your cooperation and assistance during this desk review process. Should you have additional questions or concerns please call (540) 332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on the desk review of four resident records the following was identified as not included on the individualized service plan or did not match additional assessments reviewed. Resident A - Although individual eats independently the physical indicates that assistance is required with opening carton and cutting up food. The individual is noted to require two persons to assist with basic transfers but does not indicate if that is also the case related to bathing, dressing and toileting assistance. Resident B - The assessment indicates independence with transfers and eating but service plan states two person assists with shower transfer and "will be spoon fed" for meals. The assessment indicates that individual can wheel self but service plan notes assistance would be needed to evacuate in an emergency. Resident C - Due to diagnosis, the service plan does not indicate if resident has the ability to use the call bell system. It does note time frames for checking if the individual needs to use the bathroom but no additional information. Resident D - Due to diagnosis, the service plan does not indicate if resident has the ability to use the call bell system. Individual requires the use of a wander guard but there is no indication how often it is tested or staff monitor to ensure it is on the individual.
Plan of Correction:	As the new nurse becomes more familiar with individuals and completes training all service plans and assessments will be reviewed and updated as applicable. The nurse with the administrator assume responsibility for correction and future compliance. Those issues already identified will be addressed immediately.
Standard #:	22VAC40-73-680-D
Description:	Based on a desk review of a random selection of medication administration records (MARs), documentation indicated that medication was not being administered as per physician orders or with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing consistently. Resident A: No parameters when to call physician if PRN (ass needed) medication isn't effective; multiple medications for pain with no indication which is to be given first; multiple use diagnosis for haldol. Resident B: Multiple medications not available in a timely manner - one up to seven doses; initials circled with no explanation why. Resident C: No parameters when to contact physician or what is being monitored related to breakfast blood sugar checks; blood sugar checks were twice daily and notes changed in November, 2019 but still on MAR; no parameters for PRN medications. Resident D: No parameters for PRN buspar to include how closely it can be given to scheduled dose - how is anxiety expressed and is individual asking for, particularly around same time in the mornings. Resident E: No parameters for PRN medications or what you are monitoring with twice weekly weights. Resident F: Time frames for acetaminophen every six hours do not match orders and clarification should be obtained to determine if during wake hours or individual is to be awaken for medication at midnight. Resident G: Sliding scale insulin is not being given as per the dosage requirements on the sliding scale; need parameters for PRN medication. Resident H: Medication not available for up to ten days; parameters needed for PRN medication and hold parameters for Novolin N 50 units in am - the "hold" parameters for 5 units of Noviln R do not fit the reasons for not giving as it relates to blood sugars or not eating (no documented justification); no indication what weekly weights are monitoring. Resident I: Has scheduled valium at 6am, 11am and 5pm - according to documentation she also received a PRN dosage at 10am on 7/10/2020 - need clarfication for time frames for scheduled versus PRN dosage; need parameters for all PRN medications. Resident J: Blood sugar checks are three times weekly with no indication when to contact physician; pain medication was given and noted to "help some" with no indication of follow up. PRN medications need parameters.
Plan of Correction:	All MARS and orders will be reviewed to include parameters - it is understood this can be a statement on the MAR that would include all PRN medication on that MAR and does not have to be with each individual medication. Exceptions to this would be scheduled medications such as insulin or medication for pulse rate or blood pressure. All medication aides will immediately receive training on the use of sliding scale insulin and related documentation including space adjustments being made on the MAR. They will also receive additional training on documentation of the use of PRN medication. An alternative plan will be developed regarding obtaining medication in a timely manner.When medication cannot be obtained immediately documentation will include the reason such as awaiting insurance approval and that the physician has been notified of a change in start date. Family not providing in a timely manner will no longer be accepted as justification. Orders related to regular weighing, blood sugar checks without insulin or blood pressure and pulse checks as examples will include what staff should be observing to report back to the the physician. The nurse and administrator assume responsibility for correction and future compliance.