VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Willows at Meadow Branch
1881 Harvest Drive
Winchester, VA 22601
(540) 667-3000

Current Inspector: Jill James (540) 418-2631

Inspection Date: April 21, 2021 and April 28, 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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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. When physician instructions indicate a request for notification, that action should be noted on the MAR as being done. 2. When there is a problem securing a medication from the pharmacy the specific reason for the delay should be noted on the MAR. 3. If there are circumstances under which lantus would be held they should be noted in the order and not left at the discretion of the medication aide. 4. Although hospice requests an "as needed" medication for an individual the actual reason it was given must be included on the MAR and not just "per hospice social worker or nurse as noted on the MAR for resident G. 5. When using agency staff a facility staff needs to be working with them at all times - the schedule did not consistently indicate such.

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 monitoring inspection was initiated on 4/21/2021 and concluded on 4/28/2021. The administrator was contacted by email to initiate the inspection. The current census was reported to be 49. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records plus five additional medication records, additional wound care notes and incident reports, 3 staff records plus background check information for seven staff hired since the last inspection, documentation related to fire and health inspections, health care over site, emergency drills, pharmacy review, dietary oversight, staff schedules and additional training records and certification for staff as applicable to their positions. The information gathered during the inspection determined no violations and applicable standards or law. No violations were issued. Thank you to the staff for your assistance and cooperation during this remote inspection process. Should you have additional concerns please call (540) 332-2330 or email this inspector at sharon.deboever@dss.virginia.gov.