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. 11, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 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 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/11/2022 8:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 2 plus 4 family members Number of interviews conducted with staff: 3 plus 1 hospice nurse Observations by licensing inspector: Overall, the building was clean. Postings were as required. The lunch meal observed appeared to meet physician orders and dietary requirements. Emergency drills were documented. Fire: 6/21/22 Health: 2/15/22 Additional Comments/Discussion: Discussed with the administrator the overall healthcare-staffing crisis that all facilities are experiencing. The facility has made the decision not to admit anyone with intensive needs at this time due to this issue. Recommendations were also made to update some of the policies and the facility agreement. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Five of the six staff records reviewed did not have the six hours of training within the first four months as it relates to working with individuals with cognitive impairments.
Plan of Correction:	It has been difficult with the staffing shortage to also get training completed for staff beyond our initial orientation. Training information that can be reviewed by staff will be obtained and some we already have. The facility will also seek outside sources for some training. The administrator and director of nursing will work with the Alzheimer's Association for additional resources and the licensing inspector. Correction and future documented compliance is also assumed by these parties.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of 6 resident records, five of the six staff did not have current first aid training. CPR training was also not current but a staff person with current CPR/First Aid was identified on each shift as required. This was also confirmed by the director of nursing.
Plan of Correction:	Attempts have been made at securing classes including the director of nursing being certified as a trainer. The classes have constantly been cancelled by the training party. The facility continues to seek out a trainer or getting their staff trained. Contact has been made with the local fire department and emergency services for assistance with training. The director of nursing assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of 6 resident files, five of the files had items missing from the service plans such as hospice and home health services and needs identified on the uniform assessment instrument(UAI). Current resident rights and updated fall risk assessment were also absent from some records. Observation indicated that UAIs and plans were current in regards to review dates. Residents and families interviewed indicated services were being received as needed.
Plan of Correction:	All files are being reviewed and corrections made accordingly. The facility is going to add review of resident rights on the service plan to better ensure that they are always current and happen annually. The director of nursing along with trained assigned staff assume responsibility for corrections and future compliance.
Standard #:	22VAC40-73-860-G
Description:	Based on a walk thru of the facility, water temperatures in rooms 36 and 37 and even numbers on Nelson Hall exceeded the maximum temperatu40-73-260re of 120 degrees Fahrenheit.
Plan of Correction:	A plumber will be contacted immediately to see what adjustment can be made in the water heater. If an adjustment cannot be made, individual regulators will be placed on sinks and showers for that specific area. Maintenance will monitor those specific rooms on a weekly basis to quickly address any temperature issues. Documentation will be maintained in the administrator?s office. Correction was implemented immediately.