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 22, 2024

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds Emergency Preparedness Additional Requirements for Facilities that Care for Adults with Cognitive Impairments Background Checks for Assisted Living Facilities Sworn Statement

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: 04/22/2024 & 04/29/2024 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: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch. This LI also observed a medication administration pass. Additional Comments/Discussion: An exit meeting will be 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to accurately describe the resident?s needs on the Individualized Service Plan (ISP). Evidence: 1. Uniform Assessment Instrument (UAI) dated for 11/01/2023 for Resident B indicates no help needed for dressing and the ISP states the resident needs `complete assistance? to dress/undress, locate clean clothes, and select clothes. 2. UAI dated 02/10/2024 for Resident C indicates resident needs Mechanical and Physical Help with bathing, and the ISP states complete assistance to bathe, assistance getting in/out of shower, preparing the bath, adjusting temperature, assist with washing lower legs and back, shampoo and rinse hair, towel drying, assist with dressing and monitor breathing patters and encourage rest, but does not list the needed mechanical assistance devices. 3. The ISP dated 10/20/2023 for Resident D states the resident?s medications are provided by Certified Med Tech/Licensed Nursing Staff when the resident is administering her own medications. Staff F stated that the resident is taking her own medications and updated the ISP to self-administering medications.
Plan of Correction:	UAIs and ISPs for these residents have been reviewed and updated accordingly. Assigned staff will conduct additional reviews for all residents to ensure they reflect their current needs. Random checks will be made by the administrator to ensure future compliance.