Willows of Richmond

In the surveyor’s words

From the most serious findings on record at Willows of Richmond, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF921May 30, 2025

  Based on observation and interview, the facility failed to maintain the kitchen in a sanitary manner with a black substance on the walls lining the dish sink and failed to ensure the walk-in freezer was maintained from ice buildup. This had the potential to affect 49 of 51 residents who consumed food from the kitchen. (Facility) Findings include: During a tour of the kitchen with the Dietary Manager (DM) on 5/27/25 at 11:30 a.m., a black substance was noted all along the dish sink area beside the dishwasher. The black substance lined the entire length of the sink, and some were also noted underneath the soap dispenser on the wall above the sink area. […]

• No harm, potential for more than minimal, widespreadF812Jan 18, 2024

  Based on observation, interview and record review the facility failed to maintain the kitchen in a sanitary manner with food debris between the baseboards and walls, cockroaches walking around on the floor and baseboards loose and in disrepair this had the potential to affect 50 of 50 residents who ate their meals from the kitchen. Finding include: During an observation and interview with the Dietary Manager on 1/18/24 at 11:10 a.m., there were several cockroach traps through out the kitchen with cockroaches in them, there were three cockroaches walking around the kitchen floor. The Dietary Manager killed the three cockroaches and indicated the facility had a problem with cockroaches for several months. […]

• No harm, potential for more than minimal, widespreadF925Jan 18, 2024

  Based on observation, interview and record review the facility failed to maintain an effective pest control program to prevent the facility from being free of cockroaches this had the potential to affect 51 of 51 residents residing at the facility. Finding include: During an observation on 1/18/24 at 11:00 a.m., 4 of 4 dumpster's behind the facility had their lids open with bags of trash visible and there was food and trash around the dumpster's. There were large black birds inside the dumpster's and outside the dumpster's. During an observation and interview with the Dietary Manager on 1/18/24 at 11:10 a.m., there were several cockroach traps through out the kitchen with cockroaches in them, there were three cockroaches walking around the kitchen floor. […]

• No harm, potential for more than minimal, patternF641Apr 19, 2024

  Based on interview and record, the facility failed to accurately encode the smoking status/tobacco use of Resident 30, the date of contraindication of a gradual dose reduction (GDR) for Resident 41's antipsychotic medications, the 6 month or less prognosis for Resident 50, the planned status of a discharge for Resident 51, and the utilization of non-invasive mechanical ventilation for Resident 103. This deficient practice affected 5 of 19 residents reviewed for Minimum Data Set (MDS) accuracy. Findings include: 1. The clinical record for Resident 30 was reviewed on 4/18/2024 at 11:04 a.m. The medical diagnosis included chronic obstructive pulmonary disease. An Annual MDS Assessment, dated 2/1/2024, indicated that Resident 30 did not utilize tobacco products. […]

• No harm, potential for more than minimal, isolatedF585Oct 15, 2025

  Based on interview and record review, the facility failed to assure a grievance was forwarded to the grievance official for a lost item for 1 of 4 residents reviewed for grievances.(Resident B) Findings include:The clinical record for Resident B was reviewed on 10/14/25 at 1:30 p.m. The diagnoses included, but were not limited to, hypertension and flaccid hemiplegia ( a condition where one side of the body experiences weakness and loss of muscle tone).The Annual Minimum Data Set (MDS) assessment, dated 9/5/25, indicated Resident B was cognitively intact.During an interview with Resident B, on 10/14/25 at 2:05 p.m., the resident indicated they had lost their cell phone a couple of months ago. […]