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: May 9, 2022

Complaint Related: No

Areas Reviewed:

MARK AREAS REVIEWED AREAS OF STANDARDS X22VAC40-73 GENERAL PROVISIONS X22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES X22VAC40-73 PERSONNEL X22VAC40-73 STAFFING AND SUPERVISION X22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS X22VAC40-73 RESIDENT CARE AND RELATED SERVICES X22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS X22VAC40-73 BUILDINGS AND GROUND X22VAC40-73 EMERGENCY PREPAREDNESS X22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY X32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS X63.2 GENERAL PROVISIONS X63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS X22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES X22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION X22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT ]VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

1.Recommend the facility add readings and units given directly on the MAR as opposed to keeping a second record which results in no or incorrect transcriptions for blood glucose levels and units administered. 2. It is recommended that the facility do intermittent assessments for persons self-administering medication beyond the initial physician?s order and documentation on the UAI. 3.Reviewed information regarding reporting wound care with the new nurse along with fall risk assessments requiring an update following each fall and indicating the safety plan for the individual. Two inspectors conducting review.

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: 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: 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: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Postings were as required. Meals served as per orders and as per menu. Other outside inspections current: health care oversight, pharmacy, dietary. Emergency drills as required. Additional Comments/Discussion: Fire Inspection ? 4/14/22 Health Inspection ? 3/16/22 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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