Inspection Reports for
The Willows at Meadow Branch
1881 Harvest Drive, WINCHESTER, VA, 22601
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
89% better than Virginia average
Virginia average: 9.1 deficiencies/year
Deficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
73 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Monitoring
Census: 73
Deficiencies: 0
Date: Jun 20, 2025
Visit Reason
The inspection was a monitoring visit conducted on June 20, 2025, following a complaint received on January 1, 2025, regarding staffing and supervision.
Complaint Details
A complaint was received by VDSS Division of Licensing on 1/01/2025 regarding allegations in the area of staffing and supervision. The evidence gathered did not support the allegation of non-compliance.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law related to staffing and supervision. Residents were observed in various activities and gathering for dinner, and an exit meeting was planned to review findings.
Report Facts
Number of residents present: 73
Number of interviews conducted with staff: 3
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Inspection Report
Monitoring
Census: 73
Deficiencies: 2
Date: Jun 20, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at The Willows at Meadow Branch assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to medication management and emergency procedure documentation. Violations were documented and a plan of correction was requested to address these issues.
Deficiencies (2)
The facility failed to ensure medications ordered for as needed (PRN) administration were available, properly labeled for the specific residents, and properly stored.
The facility failed to ensure that every six months staff on duty on each shift participated in an exercise in which procedures for resident emergencies were practiced and documented.
Report Facts
Number of residents present: 73
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
Inspection Report
Renewal
Census: 61
Deficiencies: 1
Date: Apr 22, 2024
Visit Reason
The inspection was a renewal inspection conducted on April 22 and April 29, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws related to the accuracy of Individualized Service Plans (ISPs) for residents. Violations were documented and a plan of correction was requested to address these issues and maintain future compliance.
Deficiencies (1)
The facility failed to accurately describe the resident's needs on the Individualized Service Plan (ISP), including discrepancies between Uniform Assessment Instruments and ISPs for residents B, C, and D.
Report Facts
Number of residents present: 61
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
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-07-26 regarding allegations in the area(s) of resident care and related services.
Complaint Details
Complaint received on 2023-07-26 regarding allegations in resident care and related services; investigation did not substantiate the complaint.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt of the inspection summary.
Report Facts
Number of residents present: 64
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
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-10-19 regarding allegations in administration and administrative services, staffing and supervision, and resident care and related services.
Complaint Details
Complaint received on 2023-10-19 regarding administration and administrative services, staffing and supervision, and resident care and related services. The investigation did not substantiate the allegations.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting will be conducted to review them.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 14
Staff interviews conducted: 1
Resident interviews conducted: 0
Inspection Report
Monitoring
Census: 61
Deficiencies: 2
Date: May 25, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable regulations and standards at the assisted living facility.
Findings
The facility was generally well maintained with no issues identified in the physical plant. However, non-compliance was found in two areas: service plans lacked consistent updates on fall risk assessments and other resident needs, and staff records lacked documentation of annual review of resident rights.
Deficiencies (2)
Service plans neither consistently contained updated fall risk assessments, identifying specific mechanical supports needed, use of hearing aids, diet changes, behavioral interventions, and mental health services; no indication that a copy of the plan had been offered to the resident.
No documentation of annual review of resident rights in staff records and interviews.
Report Facts
Number of residents present: 61
Number of resident records reviewed: 8
Number of staff records reviewed: 8
Number of resident interviews: 4
Number of staff interviews: 5
Number of non-compliance standards: 2
Inspection Report
Renewal
Deficiencies: 0
Date: May 9, 2022
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and regulations.
Findings
The inspection found no violations with applicable standards or laws. Technical assistance was provided regarding medication administration records, intermittent assessments for self-administering medication, and wound care reporting. Observations confirmed required postings, proper meal service, and current outside inspections.
Report Facts
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
Inspection Report
Monitoring
Census: 49
Deficiencies: 0
Date: Apr 21, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to review compliance with applicable standards and laws.
Findings
The inspection reviewed resident records, medication records, wound care notes, incident reports, staff records, background checks, fire and health inspections, emergency drills, pharmacy review, dietary oversight, staff schedules, and training records. No violations or deficiencies were found during this inspection.
Report Facts
Resident records reviewed: 3
Medication records reviewed: 5
Staff records reviewed: 3
Background checks reviewed: 7
Viewing
Loading inspection reports...
