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Westminster At Lake Ridge
12185 Clipper Drive
Lake ridge, VA 22192-2236
(703) 496-3400

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: July 24, 2020

Complaint Related: No

Areas Reviewed:
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 ACCOMODATIONS AND RELATED PROVISIONS
22VAC40-73 BUILDING AND GROUNDS
22VAC40-73 EMERGENCY PREPAREDNESS
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Article 1
Subjectivity

Comments:
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 renewal inspection was initiated on 07/22/2020 and concluded on 07/24/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 27. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, and other documentation submitted by the facility to ensure documentation was complete.
Information gathered during the inspection determined a non-compliance with applicable standards or law, and violation was documented on the violation notice issued to the facility.

Violations:
Standard #: 22VAC40-73-450-C
Description: Based on chart review as part of the virtual renewal inspection, it was determined the facility did not provided a description of all identified needs and date identified on a resident?s individualized service plan (ISP).

Evidence:

Resident A has private duty personnel to assist her. This care need was not addressed on the current ISP

Plan of Correction: The Unit Manager in collaboration with the Director of Nursing will conduct a 100% audit on all residents utilizing private duty services to ensure this is incorporated in the Individualized Service Plan (ISP). The Unit Manager on an ongoing basis will identify and document on the ISP any new resident receiving private duty services.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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