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:

Complaint Related: No

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in the current registered medication aide curriculum approved by the Virginia Board of Nursing to prevent the use of outdated medication.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.