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: Dec. 18, 2023

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 Background Checks for Assisted Living Facilities Sworn Statement

Comments:

Date of Inspection: December 18, 2023 Type of Inspection: Monitoring inspection Census: 39 Number of records reviewed and interviews conducted- 6 records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed residents participating in activity programs and eating lunch and dinner. Licensing Inspector observed medication administration and compared physician orders to the medications available for residents. 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. 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).

Violations:

Standard #:	22VAC40-73-150-B
Description:	Based on staff interview, it was determined that the facility failed to notify the department?s regional licensing office within 14 days of a change in the facility?s administrator. Evidence: Facility did not inform the regional licensing office regarding the change in administrator.
Plan of Correction:	Facility will notify the department?s regional licensing office within 14 days of a change in the facility?s administrator. This will be added to our facility?s QAPI review, monthly x 3, quarterly x 3.
Standard #:	22VAC40-73-440-B
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have the administrator sign the completed Uniform Assessment Instrument (UAI). Evidence: Resident A, B and C?s UAI was not signed by the administrator.
Plan of Correction:	Facility administrator will sign completed UAI?s. This will be reviewed at the daily morning meetings. And this will be added to our facility?s QAPI review, monthly x 3, quarterly x 3.