Inspection Reports for Evermore Senior Living of Lake Ridge
4358 Prince William Pkwy, Woodbridge, VA 22192, United States, VA, 22192
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Inspection Report
Renewal
Census: 55
Deficiencies: 5
Jul 17, 2025
Visit Reason
The inspection was conducted as a renewal inspection to evaluate compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure required cognitive impairment training for direct care staff, lack of training documentation for staff placed in charge, unauthorized changes to resident medication/treatment without valid physician orders, incomplete semi-annual emergency preparedness plan review, and failure to conduct fire drills on all shifts each quarter.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure direct care staff attended at least 10 hours of training in cognitive impairment within four months of employment. |
| Facility failed to provide training and written documentation to staff prior to being placed in charge. |
| Facility failed to ensure no medication or treatment was changed without a valid order from a physician or prescriber. |
| Facility failed to ensure the semi-annual review of the emergency preparedness plan included all six required elements. |
| Facility failed to ensure fire drills were conducted on each shift in a quarter. |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews with residents: 6
Number of interviews with staff: 6
Date of physician order: May 14, 2025
Oxygen liter setting: 2
Fire drill dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 6 | Direct care staff who did not complete required cognitive impairment training | |
| Staff 4 | Designated direct care staff person in charge without required training documentation | |
| Staff 1 | Staff who confirmed training deficiencies and fire drill observations | |
| Staff 2 | Staff who confirmed training deficiencies and fire drill observations | |
| Staff 3 | Staff who confirmed oxygen order and medication administration record |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Mar 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-02-18 regarding allegations in the area of resident care at the facility.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, including failure to report major incidents within 24 hours and failure to ensure treatments were changed only with valid physician orders.
Complaint Details
Complaint related: Yes. The complaint was received on 2025-02-18 regarding resident care. The evidence gathered did not support the allegation of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| The facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
| The facility failed to ensure treatments were not changed or discontinued without a valid order from a physician or other prescriber. |
Report Facts
Residents present: 52
Resident records reviewed: 2
Staff interviews conducted: 3
Resident interviews conducted: 1
Incident audit percentage: 10
Wound care order audit percentage: 10
Inspection Report
Monitoring
Census: 52
Deficiencies: 1
Mar 10, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services standards.
Findings
The facility failed to follow its own policies and procedures related to the use of gait belts during resident transfers, as confirmed by staff interviews and record reviews.
Deficiencies (1)
| Description |
|---|
| Facility failed to follow their own policies and procedures regarding the use of gait belts during resident transfers. |
Report Facts
Number of residents present: 52
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Census: 56
Deficiencies: 2
Aug 15, 2024
Visit Reason
The inspection was conducted as a regulatory visit categorized as 'Other' to review compliance following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to failure in staff communication and supervision, including an incident where a resident eloped from the memory care unit. The facility failed to maintain proper written communication logs and adequate supervision of residents, particularly those with cognitive impairments.
Complaint Details
The visit was not complaint-related but was triggered by a self-reported incident regarding resident care. The evidence gathered supported the self-report of non-compliance.
Deficiencies (2)
| Description |
|---|
| 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. |
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Number of residents present: 56
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
Inspection Report
Monitoring
Census: 50
Deficiencies: 0
May 11, 2023
Visit Reason
The inspection was a monitoring visit to review various areas including administration, personnel, resident care, buildings and grounds, emergency preparedness, and safety.
Findings
The Licensing Inspector reviewed records, conducted interviews, observed residents during meals and activities, and examined documents such as health care oversight, dietician report, fire drills, menus, activities calendars, resident council reports, pharmacy review, and resident rights review.
Report Facts
Records and interviews conducted: 10
Inspection Report
Renewal
Census: 71
Deficiencies: 0
Aug 17, 2021
Visit Reason
A renewal inspection was initiated on August 17, 2021 and concluded on August 24, 2021 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection included review of resident and staff records, staff schedules, healthcare oversight, and dietician reports. No violations were found and no deficiencies were issued.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Census: 71
Inspection Report
Monitoring
Census: 70
Deficiencies: 0
Nov 16, 2020
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards.
Findings
The inspection reviewed resident and staff records, activities, emergency drills, dietician reports, and staff trainings, and determined no violations with applicable standards or law; no violations were issued.
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