3 Reports · 1 Summary
Inspection Summary
6 inspections covered, Oct 2021 – Oct 2025.
Inspection Reports Summary
Visit Reason
This report covers six inspections of Lake Prince Woods from October 5, 2021 to October 16, 2025 by the Virginia Department of Social Services.
Findings
Across that history VDSS cited 24 violations under 19 distinct standards. All 6 inspections recorded violations.
Violations (24)
22VAC40-73-460-D: Failed to provide supervision of resident’s schedule, care, and activities including fall and wandering prevention.
22VAC40-73-550-G: Failed to annually review rights and responsibilities of residents with each staff person.
22VAC40-90-40-C: Employed person with criminal history containing barrier crime convictions.
22VAC40-73-890-B: Interior areas not adequately lighted for safety and comfort.
22VAC40-90-30-B: Failed to complete sworn statement or affirmation for all employment applicants.
22VAC40-73-1120-B: Failed to provide at least 21 hours of scheduled activities weekly with two hours daily.
22VAC40-73-640-A: Medication management plan failed to prevent use of outdated medications.
22VAC40-73-550-G: Failed to annually review rights and responsibilities of residents with each resident or representative.
22VAC40-73-1110-B: Failed to review appropriateness of continued residence in special care unit every six months and annually.
22VAC40-73-650-A: Medication started, changed, or discontinued without valid physician order.
22VAC40-73-640-A: Medication management plan failed to prevent use of outdated medications.
22VAC40-73-660-A-3: Medication cart unlocked and unattended with keys left in lock.
22VAC40-73-680-D: Medications not administered per physician instructions and standards.
22VAC40-73-450-F: Failed to update individualized service plans for significant resident condition changes.
22VAC40-73-260-A: Direct care staff lacked current first aid certification.
22VAC40-73-640-A: Medication management plan failed to prevent use of outdated medications.
22VAC40-73-1090-A: Failed to assess residents by licensed psychologist or physician for serious cognitive impairment prior to admission to safe, secure environment.
22VAC40-73-450-C: Failed to complete comprehensive individualized service plan within 30 days after admission including required items.
22VAC40-73-980-A: First aid kit missing required items and contained expired antiseptic ointment.
22VAC40-73-640-A: Medication management plan failed to ensure timely filling and refilling of prescriptions to avoid missed dosages.
22VAC40-73-620-A: Failed to ensure dietitian or nutritionist oversight every six months for residents with special diets.
22VAC40-73-450-C: Individualized service plan lacked description of resident’s identified needs based on assessment.
22VAC40-73-960-B: Fire and emergency evacuation drawing lacked areas of refuge and assembly areas.
22VAC40-73-650-E: Resident’s record lacked physician’s signed written order or dated oral order notation for medications observed.
Report Facts
Violations cited: 24
Distinct standards: 19
Inspections on page: 6
Inspections with violations: 6
Complaint visits: 0
Individual Reports
One document per inspection visit.
Inspection Report — Feb 3, 2022
Routine
Date: Feb 3, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, including ensuring residents' needs and preferences are accommodated and monitoring antibiotic use.
Findings
The facility failed to keep Resident #2's call bell within reach, posing a risk for falls, and failed to ensure timely administration of antibiotics for Resident #21, resulting in delayed treatment of a urinary tract infection.
Violations (2)
Facility staff failed to ensure Resident #2's call bell remained within reach, despite care plan interventions to minimize fall risk.
Facility staff failed to ensure Resident #21 received timely antibiotic treatment despite documented urinary tract infection and susceptibility to prescribed antibiotic.
Report Facts
Residents in survey sample: 19
Residents affected: 1
Residents affected: 1
Urine specimen colonies: 100000
Antibiotic dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Practical Nurse (LPN) #1 | Removed Resident #2's call light from behind bed and attached it to resident's covering | |
| Director of Nursing | Interviewed regarding call bell policy and antibiotic delay; stated call bell should be within reach and antibiotic delay was unjustified | |
| Nurse Practitioner (NP) | Ordered urine culture and antibiotic treatment for Resident #21 |
Inspection Report — Aug 29, 2019
Date: Aug 29, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use of psychotropic medications, specifically to ensure that residents are free from unnecessary administration of such medications.
Findings
The facility failed to ensure that Resident #16 had a 14-day stop date on the physician-ordered Ativan medication, which was necessary to reassess the need for continued use. The Director of Nursing stated the lack of a stop date was due to the resident being in hospice care.
Violations (1)
Failure to have a 14 day stop date on the use of Ativan ordered for Resident #16.
Report Facts
Residents in survey sample: 15
Medication order date: Jul 29, 2019
Assessment Reference Date: Aug 1, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Notified by surveyor of findings and provided explanation regarding medication order |
Inspection Report — Nov 16, 2017
Complaint Investigation
Date: Nov 16, 2017
Visit Reason
The inspection was conducted based on complaint-related concerns regarding medication administration, care planning, wound care, infection control, medication storage, food safety, and clinical record accuracy at Lake Prince Woods, Inc.
Complaint Details
The visit was complaint-related, triggered by concerns about medication administration errors, care planning deficiencies, infection control lapses, environmental safety, and clinical record inaccuracies. Substantiation status is not explicitly stated.
Findings
The facility failed to follow physician orders for medication administration, ensure proper care planning for psychoactive medications, implement non-pharmacological interventions prior to analgesic use, maintain infection control during wound care and glucometer use, secure medication carts, store and prepare food safely, maintain a sanitary environment, and keep accurate clinical records.
Violations (10)
Facility staff failed to notify the physician that Phoslo 667 mg capsule was not administered as ordered for Resident #1 due to dialysis absences.
Facility staff failed to include documentation dates in section V of the MDS for Resident #6.
Facility staff failed to develop a psychoactive care plan for Resident #1 receiving Zoloft.
Facility staff failed to ensure non-pharmacological interventions were attempted prior to administration of analgesics for Residents #1, #4, and #8.
Facility staff failed to ensure infection control practices during sacral wound care dressing for Resident #1.
Facility staff failed to secure treatment cart containing medication in the hallway when not in direct sight of the nurse.
Facility staff failed to store and prepare food with professional standards for food service safety.
Facility staff failed to ensure infection control measures of hand hygiene and proper disinfection during glucometer use and wound care for Residents #14 and #1.
Facility staff failed to provide a safe, sanitary, and comfortable environment; observed trash, debris, mold, dead bugs, and non-functioning lights in various facility areas.
Facility staff failed to ensure the Treatment Administration Record (TAR) was accurate for application of ted hose for Resident #1; resident was observed without ted hose despite documentation of application.
Report Facts
Medication non-administration days: 11
Medication non-administration days: 11
Medication non-administration days: 5
Days of Tylenol administration without prior non-pharmacological intervention: 18
Days of Tylenol administration without prior non-pharmacological intervention: 5
Days of Tylenol administration without prior non-pharmacological intervention: 7
Acetaminophen administration times: 6
Oxycodone-acetaminophen administration times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed and interviewed regarding wound care and infection control lapses |
| LPN #3 | Licensed Practical Nurse | Assisted with wound care for Resident #1 |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding glucometer use and infection control |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including medication administration, care planning, infection control, and clinical record accuracy |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care planning deficiencies for psychoactive medications |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and safety |
| Dietary Aide | Dietary Aide | Interviewed regarding food storage and safety |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental cleanliness and safety |
| NP | Nurse Practitioner | Interviewed regarding medication administration concerns for Resident #1 |
3 CMS Surveys
CMS Survey — Nov 16, 2017
Nov 16, 2017
CMS Survey — Aug 29, 2019
Aug 29, 2019
CMS Survey — Feb 3, 2022
Feb 3, 2022
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