The Willows at Meadow Branch

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: June 20, 2025 from 5:20 p.m. to 5:50 p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/01/2025 regarding allegations in the area of: STAFFING AND SUPERVISION Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:0 Number of staff records reviewed: 0 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: Residents were observed in various activities and gathering for dinner. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jill James, Licensing Inspector at (540)418-2631 or by email at jill.james@dss.virginia.gov

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/20/2025 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The licensing Inspector (LI) observed the residents during meals and medication administration. The following were reviewed at the time of inspection: menu, activity calendar, fire drills, emergency drills, dietician report, healthcare and medication oversight, fire marshal inspection, Virginia Department of Health inspection. LI reviewed corrective actions completed since the last inspection. The LI reviewed and verified liability insurance. Additional Comments/Discussion: None 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 Jill James, Licensing Inspector at 540-418-2631 or by email at jill.james@dss.virginia.gov

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

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 9:55 am on 11/13/2023 and exited at 11:55 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/19/2023 regarding allegations in the area(s)of: administration and administrative services, staffing and supervision, and resident care and related services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 14 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed residents on the memory care unit taking part in a “spa” day. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy1@dss.virginia.gov

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 9:55 am on 11/13/2023 and exited at 11:55 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7/26/2023 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

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.

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 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

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.

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

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.

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.