Virginia DSS · Assisted Living Facility

Brookdale Lake Ridge

📍 3940 Prince William Parkway, Woodbridge, VA, 22192-4513

ID 22029One Year licenseActive
7
Inspections
On record
4
With violations
Visits that cited something
3
Clean visits
Nothing cited
10
Violations cited
Individual findings
9
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Brookdale Lake Ridge was inspected 7 times between November 16, 2020 and July 17, 2025 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 10 violations under 9 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 6 of these 7 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
08/31/2026
Administrator
Dana Panek
Licensing inspector
Patricia Koval
Inspector phone
(804) 621-6046
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

7

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

July 17, 2025Inspection5 violations
Inspection dates
07/17/2025, 07/18/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/17/2025 10:00 A.M. – 3:00 P.M., 7/18/2025 10:00 A.M. – 3:30 P.M. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 6 Observations by licensing inspector: Building and grounds, dining services, activities in assisted living and memory care. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-650-A
Based on observation, document review, and staff interviews, the facility failed to ensure no medication or treatment shall be changed by the facility without a valid order from a physician or other prescriber.
Evidence
  1. During a tour of the building on 7/18/2025, the LI observed resident 5’s oxygen concentrator was set to 2 liters. During document review on 7/18/2025 it was observed the physician order for oxygen, dated 5/14/2025, was prescribed at 3 liters continuous oxygen, and the medication administration record (MAR) included the physician order for 3 liters continuous oxygen.
  2. Staff 1 and staff 3 confirmed the physician order and MAR documentation. Staff 1 and staff 3 accompanied LI to resident 5’s room and also confirmed the oxygen concentrator was set at 2 liters continuous oxygen.
Plan of correction
•Resident’s oxygen was changed to the liter ordered by physician immediately on 7/18/25. •The District Director of Clinical Services or Designee will provide re-education to the Executive and Health and Wellness Director by August 15, 2025, on verifying no treatment shall be changed by the community without an order from the physician. •The Executive Director or designee will verify retraining of all nurses on physician orders and treatment for oxygen, by August 31, 2025. •To assist with ongoing compliance, the Executive Director or designee will audit 10% of oxygen orders and treatment over the next three (3) months.
22VAC40-73-950-E
Based on document review and staff interview, the facility failed to ensure the semi annual review of the emergency preparedness plan included all six elements of this subsection.
Evidence
  1. During document review on 9/17/2025 the LI observed the semi-annual review of emergency preparedness with staff and residents did not include one of the six required elements: accessing emergency medical information, equipment, and medications for residents.
  2. During an interview with staff 1 on 7/17/2025, staff 1 confirmed the review of the emergency preparedness plan did not include all the required elements of this subsection.
Plan of correction
•Unable to retroactively provide training of all six (6) elements of the semi-annual review of the emergency preparedness plan. •The District Director of Operations will provide re- training to the Executive Director by August 15, 2025, on state requirements of the semi-annual review of the emergency preparedness plan. •The Executive Director or designee will review with residents and/or families and staff an update to the semi-annual review by September 30, 2025, which will include all six (6) elements of the state standard. •To assist with ongoing compliance, the Executive Director or designee will audit review of the preparedness and response plan through December 31, 2025 to verify completion.
22VAC40-73-190-C
Based on document review and staff interview, the facility failed to provide training to staff prior to being placed in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities.
Evidence
  1. During the document review on 7/17/2025, the LI requested the designated direct care staff person in charge written documentation for staff 4, hired 3/26/2025.
  2. Staff 1 confirmed staff 4 would be the designated staff in charge during their shift and written documentation was not completed.
Plan of correction
•Unable to retroactively train Staff Person(s) in Charge. •The District Director of Clinical Services or Designee will provide re-education on State Requirement for Designated Direct Care Staff Person in Charge to Executive Director and Health and Wellness Director by August 15, 2025. •The Executive Director or designee will verify training and education of all current staff by August 31, 2025. •To assist with ongoing compliance, the Executive Director or designee will audit 10% of new hire staff person(s) in charge within the next 3 months to verify training was completed.
22VAC40-73-1140-B
Based on record review and a staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment.
Evidence
  1. During the document review on 7/17/2025, the LI observed that the Relias training report for Staff 6, hired on 3/12/2025, did not include 10 hours of training in cognitive impairment. No additional training sources had been completed that could count toward the total required hours.
  2. Staff 2 confirmed staff 6 did not complete the required number of training hours within four months of their hire date.
Plan of correction
•Unable to retroactively correct lack of clinical employee training hours in Cognitive Impairment to include 10 hours within first four months of employment. •The Executive Director or designee will provide re-training to the Business Office Manager on state requirements of training hours in Cognitive Impairment by August 11, 2025. •The Executive Director or designee will conduct a review of the next three (3) new hires to verify completion of training in Cognitive Impairment. •To assist with ongoing compliance, the Executive Director or designee will audit 10% of new hires monthly for three (3) months.
22VAC40-73-970-A
Based on record review and staff interviews, the facility failed to ensure fire drills were conducted each shift in a quarter.
Evidence
  1. During a record review on 7/17/2025, the Licensing Inspector (LI) observed that fire drills were conducted on 4/30/2025 at 2:14 P.M., 5/28/2025 at 1:35 P.M., and 6/18/2025 at 1:25 P.M. All three drills were completed during the first shift.
  2. Staff 1 and staff 2 confirmed the fire drills were completed the first shift.
Plan of correction
•Unable to retroactively correct drills not being completed on all three shifts in the most recent quarter. •The Executive Director will conduct retraining with Maintenance Manager by August 11th, 2025. •The Executive Director or designee will conduct an audit of fire and emergency drills for the next three months to verify they are conducted on each shift per state regulations. •To assist with ongoing compliance, the Executive Director or designee will audit the upcoming drills monthly through December 31, 2025.
March 10, 2025Inspection1 violation
Inspection dates
03/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/10/2025 4:15 p.m. – 5:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds and dining services. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-40-B
Based on record review and staff interview, the facility failed to follow their own policies and procedures.
Evidence
  1. Staff 1 submitted an incident report on 2/1/2025 regarding resident 1 (admitted 1/20/2025). 2.During an interview with the Licensing Inspector (LI) on 3/10/2025, staff 1 stated that staff 3 (hired 3/25/2008) did not use a gait belt while transferring resident 1 from their wheelchair to their bed. Resident 1’s individual service plan, dated 1/20/2025, states resident requires assistance during transfers.
  2. Facility policy “Gait/Transfer/Walking Belts” stated that gait belts are to be used when assisting with ambulation.
  3. Staff 3 had received training on transfers, including the use of gate belts, on 8/10/2021, 8/4/2022, 8/24/2023, and 11/7/2024.
  4. Staff 1 confirmed staff 3 did not follow facility policies and procedures.
Plan of correction
•Unable to retroactively correct transfer. •The Executive Director and Health & Wellness Director will provided re-education to all clinical staff on safe transfers and gait belt use by June 30, 2025. •The Executive Director, Health and Wellness Director or designee will survey 5% of residents who need transfer assistance weekly for 4 weeks. •To assist with ongoing compliance, the Executive Director or designee will survey transfer for 5% of residents who need transfer assistance monthly for three months.
March 10, 2025Complaint survey2 violations
Inspection dates
03/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/10/2025 10:45 a.m. – 4:10 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/18/2025 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building and grounds, dining services, activities provided. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-650-A
Based on document review and staff interviews the facility failed to ensure treatments shall not be changed or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. During document review on 3/10/2025, the LI observed resident 2 (admitted 1/22/2025) had a physician order (dated 1/23/2025) for a hospice nurse or Brookdale staff to change resident 2’s dressing every 7 days and as needed (PRN) due to soiling.
  2. LI observed a hospice note on 2/20/2025 stating the wound dressing was not on the resident and open in the brief. Hospice notified staff on duty that the wound needs to be covered at all times.
  3. Staff 2 stated treatment orders are placed on resident medication administration record (MAR). LI reviewed the January 2025, February 2025, and March 2025 MAR’s. The physician treatment order to change the wound dressing PRN due to soiling by Brookdale staff was not included on the MAR.
  4. Staff 1 and staff 2 confirmed the physician order was not incorporated into resident 2’s MAR and followed up on.
Plan of correction
•Unable to retroactively correct wound care “as needed” orders. •The Executive Director or Designee will provide re-education on Physician or Other Prescribers orders per state regulation for the Health & Wellness Director and Health and Wellness Coordinator by June 13, 2025. •The Health & Wellness Director or Designee will audit current residents with wound care orders for accuracy and documentation reflected in the Medication Administration Record (MAR) by June 13, 2025. •The Health & Wellness Director or designee will complete an audit on current resident’s records with current wound care orders daily for 1 month for accuracy. •To assist with ongoing compliance, the Health & Wellness Director or designee will conduct an audit of 10% of residents with wound care orders for compliance monthly for 3 months.
22VAC40-73-70-A
Based on document review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. During document review on 3/10/2025, the Licensing Inspector (LI) observed resident 1 (admitted 7/1/2024) had a documented fall on 1/17/2025 and was sent to the emergency room (ER) for further evaluation due to complaints of right hip pain. Resident 1 on 1/19/2025 was again sent to the ER due to unresponsiveness. Resident 1 returned to the facility on 1/25/2025 with a new diagnosis of COVID.
  2. Staff 1 confirmed resident 1 was sent to the ER on 1/17/2025 and 1/19/2025 and incident reports were not sent to the regional licensing office.
Plan of correction
•Unable to retroactively correct incident reporting date. •The District Director of Clinical Services or Designee will provide re- education on reportable events and incidents for the Executive Director, Health and Wellness Director and Health and Wellness Coordinator by June 13, 2025. •The Executive Director or designee will conduct a daily review of any incidents and notification to VDSS per state regulations. •To assist with ongoing compliance, the Executive Director or designee will audit 10% of incidents monthly for 3 months.
August 15, 2024Inspection2 violations
Inspection dates
8/15/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Other Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/15/2024 12:37pm – 4:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6/25/2024 regarding allegations in the area of: Resident Care Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the memory care unit was conducted. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: Yes
Violations
22VAC40-73-460-D
Based on record review and interviews the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises.
Evidence
  1. Resident 1 UAI (date: 5/19/2024) identified resident as disoriented to place, time, and situations all of the time. Approved level of care was memory care.
  2. A Brief Interview Mental Status Screening (BIMMS) tool was administered (date 4/16/2024) to Resident 1 who scored 1, denoting severe cognitive impairment.
  3. Assessment of serious cognitive impairment (date 3/8/2024) administered by a licensed psychologist identified Resident 1 as unable to recognize danger or protect their safety and welfare.
  4. A incident report notifying Resident 1 eloped was submitted by Staff 5 to the Region 3 Licensing Administrator on 6/25/2024.
  5. The LI requested a copy of the facilities internal investigation which included the following timeline: on 6/24/2024, dinner trays were reportedly picked up from memory care around 5:30pm and the front concierge desk was staffed until 6:30pm and the concierge did not see Resident 1 walk past the desk.
  6. Collateral 1 reported to the LI, at approximately 8:15pm Collateral 1 received a call from a pedestrian who saw Resident 1 crossing the street at an apartment complex. The pedestrian approached Resident 1, identified resident needed assistance, noticed a bracelet with contact information on resident's wrist and called Collateral 1. The apartment complex is located approximately 1.5 miles from the facility. At approximately 8:20pm Collateral 1 called the facility and asked Staff 8 why Collateral 1 had not been notified that Resident 1 was not in the facility. Resident 1 was returned, by Collateral 1, to the facility at approximately 8:35pm the same day.
  7. Noted in the facilities Incident Investigation Report, page 3 of 6, was a note that the pass code to the memory care unit had been given to a non-associate.
  8. The Post Elopement investigation report includes a question if a security report was ran to ensure equipment was working properly and to determine how often the doors were opened? This question was marked “yes”. The LI questioned Staff 5, who completed the report, and Staff 5 could not explain why “yes” was entered when a report could not be run. Staff 7 was also questioned, and Staff 7 also reported that a report could not be run and entering “yes” should not have been entered.
  9. Staff 5 acknowledged to the LI during an interview on 8/15/2024 that the exact events and time that Resident 1 exited the building could not be determined. Staff 5 stated that a family member had access to the pass code to the secure unit should not have happened. Staff 5 stated the exact whereabout of the resident between dinner and when Collateral 1 called the facility notifying Resident 1 was not in the facility makes knowing how long the resident was outside the facility difficult. Staff 5 acknowledged that lapses occurred allowing the resident to exit the building unsupervised.
Plan of correction
• Unable to retroactively correct that an unauthorized individual had door code for the safe, secure unit. • The Executive Director, Health and Wellness Director or designee immediately updated memory care door codes and secured special care unit. • The Executive Director or designee will provide education for the Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator and clinical associates on safe, secure environment and that only staff is to have memory door codes. • To assist with ongoing compliance, The Executive Director, Maintenance Manager, Health and Wellness Director, Health and wellness Coordinator or designee will audit memory care alarms, appropriate door codes, and frequent resident rounds weekly for 4 weeks, then monthly thereafter.
22VAC40-73-300-B
Based on record review and staff interview the facility failed to have a method of written communication to keep direct care staff on all shifts informed of significant happenings or problems experienced by residents during each shift.
Evidence
  1. Resident 1 eloped on 6/24/2024 during the second shift (3:00pm –11:00pm) from the special care unit. The approximate time of elopement is between 6:30pm and 7:00pm.
  2. The LI requested copies of the communication log from June 20, 2024, to June 27, 2024.
  3. The communication log on June 24, 2024, did not include written documentation of the elopement during the 3:00pm-11:00pm and 11:00pm – 7:00am shifts.
  4. The 6/25/2024 communication log documented the elopement during the 7:00am-3:00pm shift. The LI asked Staff 6 how the staff on 6/25/2024 would be made aware of the elopement if it was not documented on 6/24/2024 and the response was Staff 8 called in the next morning to communicate the elopement to the nurse.
  5. The LI requested a copy of the facility staff communication policy. The facility provided policy: Alert Charting – 3 as their policy for shift communication. The policy describes the nurse or designee should document in the resident record. It also states associates should notify the nurse of conditions or events and the nurse should enter information in the Alert Charting Log.
  6. Staff 4 and Staff 6 acknowledged that only nurses document in the communication log. They also acknowledged that the communication log did not communicate the elopement for each shift.
Plan of correction
• Unable to retroactively correct staff communication report for resident number 1. • The Executive Director, Health and Wellness Director or Designee will initiate a communication log to keep direct care staff informed of significant situations during each shift. • The Executive Director, Health and Wellness Director or designee will provide reeducation for all associates on staff communication report of significant situations. • To assist with ongoing compliance, The Health and Wellness Director or Designee will audit communication log daily time 2 weeks and weekly thereafter.
May 11, 2023Inspection0 violations
Inspection dates
05/11/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: May 11, 2023 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@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 50 Number of records reviewed and interviews conducted- 10 records (residents and staff), 10 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meal times and activities. The Licensing Inspector reviewed the following at the time of inspection: health care oversight, dietician report, fire drills, menus, activities calendars, resident council reports, pharmacy review and resident rights review.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 17, 2021Inspection0 violations
Inspection dates
08/17/2021,08/17/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
A renewal inspection was initiated on August 17, 2021 and concluded on August 24, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator0 reported that the current census was 71. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, healthcare oversight, and dietician report submitted by the facility to ensure documentation was complete. An exit interview was conducted with the Administrator where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 16, 2020Inspection0 violations
Inspection dates
Nov. 16, 2020 and Nov. 20, 2020
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS
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 monitoring inspection was initiated on November 16, 2020 and concluded on November 20, 2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 70. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, activities calendar, staff schedules, emergency drills, dietician report and staff trainings submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.