VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Legacy Ridge Memory Care Community
16001 Loves Mill Lane
Gainesville, VA 20155
(703) 468-7000

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: July 19, 2023

Complaint Related: No

Areas Reviewed:

Personnel Staffing and Supervision Resident Care and Related Services Building and Grounds Emergency Preparedness Background checks for Assisted Living Facilities Sworn Statement Criminal History Record Report

Comments:

Date of Inspection: July 19, 2023 Type of Inspection: Monitoring inspection Census 56 Number of records reviewed and interviews conducted- 3 records, 3 interviews. The Licensing Inspector observed residents participating in activity programs. This Licensing Inspector walked through the facility as well as area for staff only. 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.

Violations:

Standard #:	22VAC40-73-1040-A
Description:	Based on staff interview, it was determined that the facility failed to prevent residents from leaving the facility unsupervised. Evidence: On 7/13/2023 Resident A and B left the facility unsupervised and were located by staff. Residents were unharmed and returned to the facility.
Plan of Correction:	After reviewing the cameras, it was discovered that the residents went through a door that the door latch had not engaged to secure it. Several vendors were called to come, check and offer all alternatives to resolve the door issue and prevent this from occurring again. Until the door has been completely secured, hired agency staff or one of the community staff will be posted 24/7 near the door to ensure no residents are able to go through it without an escort. All staff, agency, vendors and visitors will be re-educated on monitoring all doors that always leave the neighborhood and to double check door latches behind them. The Executive Director or Designee is responsible for implementation and ongoing compliance with all components of this plan of correction and addressing/resolving any variance that may occur.