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 13, 2023

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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

1.Reviewed with hospice nurse the need for additional instructions and monitoring for dietary staff when diet texture is changed. 2.Additional updates are needed for disclosure and agreement especially as it relates to residents receiving auxiliary grants. 3.Reviewed MAR formatting for blood glucose monitoring and use of sliding scale insulin that follows best practices. 4.Physician needs to provide clearer guidelines for the use of glucagon in the event of hypoglycemia. 5. Physician needs to clarify parameters of when to hold and when to contact the physician as it relates to all insulin orders.

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: 7/13/23 The Acknowledgement of Inspection form was signed and left at the facility on the date of the inspection. Number of residents present at the facility at the beginning of the inspection: 44. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. As noted in the violation portion of this report hot water temperatures exceeding the maximum were identified during the tour. The menu was posted and followed. There was no activity schedule available for review as noted in the violation report. The facility was clean and odor free. Number of resident records reviewed: 8 Number of staff records reviewed: 8 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 plus 1 collateral (hospice nurse) Observations by licensing inspector: The residents interviewed and observed voiced no complaints or concerns about the care they received. The med cart was clean and organized and medication was received as scheduled. The schedule II drug count was exact. A review of the schedule indicated the facility has staff as per the requirements for a mixed population to meet the needs of the current residents but as the owner and administrator both indicated the current health care staff shortage continues to be an issue and limits any new residents who require a higher level of care. Additional Comments/Discussion: Fire inspection forthcoming as noted below. Fire: 7/24/23 Health: 10/31/22 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 had the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed 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 minus the supplemental page. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov 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 #:	22VAC40-73-210-B
Description:	Based on a review of eight staff training records, direct care staff employed for a year or more (A, D, E, F) did not have the required 18 hours of annual training.
Plan of Correction:	The current staff health care staffing shortage has made it difficult to pull staff for training. We are working on alternative methods to acquire training for our staff to equal the required 18 hours annually. The administrator and assistant assume responsibility for correction and future compliance of the standard.
Standard #:	22VAC40-73-320-B
Description:	Based on a review of 9 resident records, annual TB screenings had not been completed for residents B, C, E and G. It was observed that staff screenings were completed as required.
Plan of Correction:	All records will be reviewed and when the physician makes his weekly visits, he will complete screenings for all applicable residents. The administrator and assistant assume responsibility for correction and future compliance.
Standard #:	22VAC40-73-440-H
Description:	Based on a review of 9 residents records the uniform assessment instruments (UAIs) had not been updated annually for the residents B, C, E and G. Observations indicated the residents were receiving all applicable services.
Plan of Correction:	All resident records will be reviewed and UAI updated as applicable to bring the facility into compliance. The administrator assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of 9 resident records the individualized service plans (ISPs) had not been updated annually for residents B, C. E, F, and G. Observations indicated the residents were receiving all applicable services.
Plan of Correction:	All resident records will be reviewed, and ISPs updated as applicable to bring the facility into compliance. The administrator assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-490-A-2
Description:	The facility did not have a current health care oversight. Since the facility does not have a full-time health care professional functioning in that capacity, they are required to have quarterly oversights. An oversight has not been completed in the last year.
Plan of Correction:	The facility will contact the pharmacy to assist with healthcare oversight in the absence of being able to secure a full-time nurse. The administrator assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-520-E
Description:	Based on a walk thru of the facility and observations throughout the day, there was no activity scheduled posted for the month of July, no daily activity schedule noted, and no activities were observed.
Plan of Correction:	The administrator will meet with the activities person to ensure that a minimum of a fourteen-hour monthly schedule is posted and will monitor to ensure the activities do occur.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of 9 resident records, annual resident rights were not reviewed with residents B, C, E, G, and H. All residents had documentation of receipt of initial resident rights.
Plan of Correction:	Resident rights will be brought up to date for all residents. The administrator and activities person assume responsibility for correction and future compliance.
Standard #:	22VAC40-73-860-G
Description:	The water temperatures in the lower hall of Nelson and in the bathroom in Buckner Hall across from the dining area were found to exceed 120 degrees Fahrenheit.
Plan of Correction:	This has been an ongoing issue for the facility. We recently installed a new water heater. We will continue to adjust the temperature controls and monitor the temperature. Residents and staff had complained it took awhile to get warm so we had turned the system up and will now return it to previous settings. Maintenance will continue to assist in correction and future compliance.