VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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 6, 2022

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

Comments:

Date of Inspection: July 6, 2022, 9:45am-3:33pm Type of Inspection: Renewal inspection If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 33 Number of records reviewed and interviews conducted- 8 records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). The completed corrective action needs to be in the licensing office by July 21, 2022

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, it was determined that the facility failed to perform subsequent TB evaluations.
Plan of Correction:	TB evaluation of staff is currently being completed. The administrator has completed an in-service of the Wellness staff on the requirements for annual screening for TB for all staff in the Assisted Living Facility. The Administrator or designee will complete annual audits of staff records for the completion of staff screening for TB. Findings will be forwarded o the QAPI Committee for further recommendations or interventions. Date of Compliance: 7/31/2022.
Standard #:	22VAC40-73-490-A
Description:	Based on record review and staff interview, it was determined that the facility failed to provide health care oversight every 6 months.
Plan of Correction:	The Health Care Oversight process has been initiated at the this time. The administrator has completed an in-service with the nursing staff on the requirements for the completion of Health Care Oversight every six months. The Director of Nursing or designee will complete random audits every six months for one year, for the completion of the Health Care Oversight as required. Findings will be forwarded to the QAPI Committee for further recommendations or interventions. Date of Compliance 7/31/2022.
Standard #:	22VAC40-73-720-A
Description:	Based on resident records review, it was determined that the facility failed to update the individualized Service Plan (ISP) for residents who had Do Not Resuscitate Orders.
Plan of Correction:	The ISPs for resident A and C have been reviewed and updated to include their Do Not Resuscitate orders. The administrator has completed an in-service of the nursing staff on the requirements for updating ISPs to reflect physician's orders for the resident. The Director of Nursing or designee will complete random audits every month for four months, for the completion of ISP updates, reflecting physician's orders.