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 25, 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:

Discussed change needed in sliding scale order to remove ?bedtime?. Discussed adding the full O2 order to the service plan as it is on MAR. Background checks need to be completed for rehires not just an updated sworn disclosure.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/25/23 The Acknowledgement of Inspection form was signed and left at the facility for the date of the inspection. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. No issues were identified. The building and grounds were well kept. The building was odor free. Water temperatures were within the required range. Number of resident records reviewed: 8 Number of staff records reviewed: 8 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Residents were involved in various activities throughout the day including an ice cream party outside. Previously they had participated in multiple activities including a dance for Apple Blossom Festival. Postings were as required, and lunch was served as per the menu. Residents interviewed voiced no concerns about care. The morning med pass was reviewed as was the medication cart. The morning med pass requires a minimum of two medication aides to complete the pass as per Board of Nursing guidelines. Additional Comments/Discussion: Outside inspections are current. Related fire drills exceed the standard requirements as each shift is done monthly. All other drills were current. Fire ? 4/12/23 Health ? 3/9/23 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with two 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. 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 #:	22VAC40-73-450-C
Description:	Based on a review of a random sample of resident records and individualized service plans neither consistently contained the following: updated fall risks assessments, identifying specific mechanical supports needed, use of hearing aids, diet changes, behavioral interventions, and mental health services. There was further no indication that a copy of the plan had been offered to the resident.
Plan of Correction:	All service plans will be reviewed and updated accordingly. Fall risk assessments will be completed annually as well as following each fall to assist in developing a new or change in the intervention plan.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of a random sample of staff records as well as interviews, there was no documentation of annual review of resident rights.
Plan of Correction:	Annual review of resident rights will be added to the annual training calendar and documented accordingly. The administrator assumes responsibility for correction and monitoring for future compliance.