Inspection Reports for Westminster At Lake Ridge
12191 Clipper Drive, LAKE RIDGE, VA, 22192-2236
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
38 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 38
Deficiencies: 0
Date: Aug 27, 2025
Visit Reason
The inspection was a monitoring visit conducted on August 27, 2025, following a self-reported incident received on July 26, 2025, regarding allegations in Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector toured the facility and grounds, reviewed one resident record, and conducted one staff interview.
Report Facts
Number of residents present: 38
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Monitoring
Census: 38
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-08-18 regarding allegations in Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to the facility's failure to assume general responsibility for the health, safety, and well-being of residents, specifically involving an elopement incident. Violations were issued and the facility was required to submit a plan of correction.
Deficiencies (1)
Based on self-reported incident and resident record review, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Report Facts
Number of residents present: 38
Number of resident records reviewed: 1
Distance resident eloped: 500
Date of self-reported incident: Aug 18, 2025
Date of inspection: Aug 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing regarding allegations in the areas of Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services.
Complaint Details
The complaint was related to Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services. The evidence gathered during the inspection found no violations.
Findings
The inspection findings determined no violations with applicable standards or laws. The licensing inspector observed residents and staff activities and conducted interviews without identifying any deficiencies.
Report Facts
Number of resident records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector conducting the complaint-related inspection |
Inspection Report
Renewal
Census: 39
Deficiencies: 1
Date: Jul 2, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for Westminster At Lake Ridge assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws, specifically a violation related to failure to ensure written assurance was provided to a resident at the time of admission.
Deficiencies (1)
Facility failed to ensure written assurance was provided to the resident at the time of admission.
Report Facts
Number of residents present: 39
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector conducting the renewal inspection |
Inspection Report
Monitoring
Census: 35
Deficiencies: 5
Date: Apr 14, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection identified multiple violations related to resident records, staff tuberculosis screening, individualized service plans, Do Not Resuscitate orders, and emergency preparedness plan reviews. The facility was found non-compliant and issued a violation notice with an opportunity to submit a plan of correction.
Deficiencies (5)
Facility failed to prepare and provide a disclosure statement to prospective residents and their legal representatives.
Facility failed to evaluate and submit annual tuberculosis screening results for staff.
Facility failed to develop Individualized Service Plans (ISP) that included written descriptions of services to address identified needs.
Facility failed to include Do Not Resuscitate orders on Individualized Service Plans.
Facility failed to implement a semi-annual review of the emergency preparedness and response plan for all staff.
Report Facts
Number of residents present: 35
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Inspection Report
Census: 36
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
The purpose of this consultation was to discuss upcoming plans to renovate the current assisted living facility to include a secured unit.
Findings
The licensing inspector completed a tour of the physical plant including the building and grounds, observed residents participating in an activity program, and conducted interviews with three staff members.
Inspection Report
Monitoring
Census: 36
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
The inspection was a monitoring inspection conducted to review administration, administrative services, and resident care at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. Observations included residents eating lunch in the dining room, and the inspection concluded with no deficiencies noted.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 39
Deficiencies: 2
Date: Dec 18, 2023
Visit Reason
The inspection was a monitoring visit to review various areas including administration, personnel, resident care, and emergency preparedness, and to observe medication administration and resident activities.
Findings
Two violations were cited: failure to notify the regional licensing office within 14 days of a change in the facility's administrator, and failure to have the administrator sign the completed Uniform Assessment Instrument (UAI) for residents.
Deficiencies (2)
Facility failed to notify the department's regional licensing office within 14 days of a change in the facility's administrator.
Facility failed to have the administrator sign the completed Uniform Assessment Instrument (UAI) for residents.
Report Facts
Records reviewed: 6
Interviews conducted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Renewal
Census: 33
Deficiencies: 3
Date: Jul 6, 2022
Visit Reason
The inspection was a renewal inspection conducted to review compliance with licensing standards and regulations for the assisted living facility.
Findings
The inspection identified violations related to failure to perform subsequent TB evaluations for staff, failure to provide health care oversight every six months, and failure to update individualized Service Plans for residents with Do Not Resuscitate orders. Plans of correction were provided for each deficiency.
Deficiencies (3)
Facility failed to perform subsequent TB evaluations for staff.
Facility failed to provide health care oversight every 6 months.
Facility failed to update individualized Service Plans for residents with Do Not Resuscitate orders.
Report Facts
Records reviewed and interviews conducted: 8
Plan of correction compliance date: Jul 31, 2022
Inspection Report
Monitoring
Census: 29
Deficiencies: 0
Date: Aug 26, 2021
Visit Reason
A monitoring inspection was initiated to review compliance with applicable standards and laws, including personnel, staffing, resident care, and emergency preparedness.
Findings
The inspection reviewed resident and staff records and fire drills, finding no violations with applicable standards or law. No deficiencies were issued.
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