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: Aug. 3, 2021 and Aug. 13, 2021

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 63.2 General Provisions. 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:

The facility provided documentation of ongoing issues with receiving state police background checks. The facility has submitted all background checks in a timely manner and have resubmitted some on multiple occasions. The state police is reviewing their input to the system. The owner will ,make the licensing office aware of updates.

Comments:

A renewal inspection was initiated on 08/03/2021 and concluded on 08/13/2021. The Director of Nursing and Administrator were contacted by email and telephone to initiate the inspection. The Director of Nursing reported that the current census was 48. The inspector emailed the Director of Nursing and Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, additional background checks for four individuals hired since the last inspection, fire inspection and related drills, healthcare and dietary oversights along with pharmacy reviews submitted by the facility to ensure documentation was complete. The health inspection is past due but the facility is awaiting a response from the health department as all inspections were held due to Covid. The inspector conducted the remote on-site portion of the inspection on 8/13/2021. Physical plant, postings, emergency food supply and medication carts were reviewed. An exit interview was conducted with Director of Nursing on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with two applicable standards or law, and violations were documented on the violation notice issued to the facility. Thank you to the staff and residents for your cooperation during this remote inspection process. Should you have additional questions or concerns please call (540) 332-2330 or email this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-520-I
Description:	Based on a walk through of the facility with the director of nursing there was no activity schedule posted or available for the month of August. The last schedule in the scheduling notebook was for July, 2021. There was further no information outlined on the daily activity board. The staff responsible for activities was not available for an interview. Snacks and listening to music were indicated by the director of nursing as the only activities she was aware of for that day.
Plan of Correction:	The administrator and director of nursing will meet with the activity staff to ensure a monthly schedule is developed and posted. All other staff will be reminded that in the absence of the activities person they are still responsible for ensuring that a minimum of 14 hours of activities are occurring weekly. This does not include snack unless accompanied by another activity.
Standard #:	22VAC40-73-680-D
Description:	Observation of three medication carts with the director of nursing indicated that facility staff assisting with medication failed to consistently follow their own medication management plan as well as standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing to prevent the use of outdated medication. Evidence: Cart 1 - Eye drops did not have a date when opened Cart 2 - None of the drops , lantus or insulin pens had dates when opened Cart 3 - No issues
Plan of Correction:	The director of nursing will provide additional training to all medication aides currently assisting with medication on proper labeling related to medications that, as per the standards of practice, expire 28-30 days after opening. Documentation of training will be maintained in the staff files. Review of the medication management plan containing this information is already a part of the orientation for all new medication aides. The Director of Nursing will further monitor the medication carts for correction and future compliance.