VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Westmont at Short Pump
14399 N. Gayton Road
Glen allen, VA 23059
(804) 495-8880

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Oct. 6, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

Technical assistance offered to facility administrator to clarify issues which led to violations of regulations during this inspection. The Licensing Inspector reviewed the following standards with provider: 22VAC 40-73-40-B; 220; 325-A; 325-B; 325-C; 330-A; 330-B; 430-H; 440-B; 460-A; 650-A; 680-I

Comments:

An unannounced renewal inspection was initiated on 10/06/2021. The facility administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 79. 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, medication administration records, nurses? notes, and other facility documentation submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/19, 20/2021. An exit interview was conducted on both days with the Director of Nursing for assisted living and the director of the facility?s safe and secure environment 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 facility Administrator was not on site at the facility on 10/19, 20/2021. The exit interview conducted on 10/20/2021 also included a representative from the facility?s regional clinical team who was on site at the facility. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance 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). If you have any questions I can be reached at (804z0 840-0253 or angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-B-12
Description:	Based on the review of facility records the facility failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in ? 63.2-1706 of the Code of Virginia. Evidence: Resident #3- Documented date of admission 04/10/2021. Documented date of discharge 07/28/2021. Upon request the facility did not submit for the inspector?s review the facility's documentation of approval and appropriateness of placement on the facility?s safe and secure unit and facility documentation for the residents receiving private duty services. Resident #4-Documented date of admission 07/27/2021. Facility records submitted for the inspector?s review revealed that upon admission the residents? personal care aide was with the resident. Upon request the facility did not submit for the inspectors? documentation that while in care the resident was receiving private duty services and what the specific services were. The facility also did not submit upon request documentation that prior to being placed in charge, facility staff #5 was informed of and received training on the duties and responsibilities and provided written documentation of such duties and responsibilities.
Plan of Correction:	FACILITY'S RESPONSE: "1. Steps to correct non-compliance with the standard: (I would make this more of a statement: Community will allow representative opportunity to inspect documents/facilities as necessary 2. Measures to prevent the non-compliance from occurring again Prior to any resident having private duty personnel in the community, the community will be provided with all required information regarding what specific services the private duty personnel will be providing. Prior to any team member being in charge in the community, they will have documented training on the duties and responsibilities of being in charge. 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
Standard #:	22VAC40-73-220-A
Description:	Based on the review of facility records the facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, that all requirements were met. Evidence: Resident #3- Documented date of admission 04/10/2021. Documented date of discharge 07/28/2021. Resident #4 Documented date of admission-07/27/2021 Facility records submitted for the inspector?s review notes that resident #s 3 and 4 received the services of a private duty individual while in care at the facility. Upon request the facility did submit for the inspector?s review documentation of whether the facility obtained, in writing, information on the type and frequency of the services to be delivered to the resident(s) by private duty personnel, reviewed the information to determine if it is acceptable, and provided notification to the home care organization regarding any needed changes.
Plan of Correction:	FACILITY'S RESPONSE: "1. Steps to correct the non-compliance with the standard Resident #3 no longer resides in the community Resident # 4 no longer has private duty personnel An audit will be completed to ensure that all required information for private duty personnel is in place. 2. Measures to prevent the non-compliance from occurring again Current nursing management will be re-educated to 22VAC40-73-220A regarding private duty personnel. Wellness Director/Director of Inspiritas Clinical and Engagement/designee will audit all residents with private duty personnel 2 times a month to ensure current accurate information regarding private duty services being provided. 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
Standard #:	22VAC40-73-325-C
Description:	Based on the review of facility records the facility failed to ensure that the fall risk rating was reviewed and updated after a fall. Evidence: Resident #4 Documented date of admission-07/27/2021 The facility?s Progress Notes document and the Morse Fall-Senior Living (assessment) documented dated 08/02/2021 for the resident revealed that a fall occurred while in care at the facility. Upon request the facility did not submit for the inspector?s review documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	FACILITY'S RESPONSE: " 1. Steps to correct the non-compliance with the standard Resident falls with be reviewed weekly at resident risk meeting weekly 2. Measures to prevent the non-compliance from occurring again Current nursing management team will be re-educated to 22VAC40-73-325-C. Wellness Director/Director of Inspiritas Clinical and Engagement/designee will review all falls to ensure that there is documented analysis of the circumstances of the fall and interventions were initiated to prevent or reduce the risk of subsequent falls 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
Standard #:	22VAC40-73-330-A
Description:	Based on the review of facility records the facility failed to ensure that a mental health screening is conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Resident #3 Documented date of admission-04/10/2021. Documented date of discharge 07/28/2021. The resident?s physician responded Yes to the question on the resident?s 03/16/2021 Report of Resident Physical Examination document that within the previous six months the resident has exhibited behaviors that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. The resident was assessed by facility on 04/10/2021, 05/28/2021 and 07/23/2021 as not needing a psychiatric or psychological evaluation. The 05/28/2021 UAI assessment document was also signed by the facility Administrator.
Plan of Correction:	FACILITY'S RESPONSE: "1. Steps to correct the non-compliance with the standard Resident #3 no longer resides in the community 2. Measures to prevent the non-compliance from occurring again Residents admitted to the community with documentation on their H&P of Yes to the question on that within the last 6 months the resident has exhibited behaviors that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and the caused or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk will be referred to the community mental health provider if the resident does not have their own mental health provider. 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
Standard #:	22VAC40-73-330-B
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that a mental health screening was conducted when a resident displays behaviors or patterns of behavior indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders that cause concern for the health, safety, or welfare of either that resident or others who could be placed at risk of harm by the resident. Resident #3 Documented date of admission-04/10/2021. Documented date of discharge 07/28/2021. Facility records submitted for the inspector?s review revealed the following: 07/23/2021: The facility submitted a self-reported incident to the department informing that on 07/22/2-21 (resident #3 identified) ?pushed resident #5 onto the floor and during the fall hit her head on an end table. Police arrived to assess the situation and speak to (resident #3 identified). Facility documentation also noted that the residents? personal care aide was present when the incident occurred. 08/02/2021: A follow up report from the facility regarding this matter notes under the heading Outcome of Incident: ?(Resident #5 identified) returned to community from ED no new orders received?. (Resident #3 identified) returned to with admission to secure Memory care Unit?. The document also notes that resident #3 was admitted to the facility?s safe and secure environment with 24 hour private care aide. The facility admitted the resident to the safe and secure environment without documentation that a mental health screening was conducted after the aggressive altercation with another resident.
Plan of Correction:	FACILITY'S RESPONSE: "1. Steps to correct non-compliance with the standard Resident #3 no longer resides in the community Current AL residents will be re-evaluated for any behaviors or patterns of behaviors. Any residents identified will be referred to the community mental health professional. 2. Measures to prevent the non-compliance from occurring again Current nursing management team will be re-educated to VAC40-73-330-B Wellness Director/Director of Inspiritas Clinical and Engagement/designee will review documentation weekly to identify behaviors or patterns of behaviors with appropriate referral to mental health documented 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
Standard #:	22VAC40-73-430-H-1
Description:	Based on the review of facility records the facility failed to ensure that at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contained all of the required elements. Evidence: Resident #3-Documented date of discharge 07/28/2021 The resident?s discharge document (state model form) that was submitted for the inspector?s review is blank in the sections requesting: ?The date of discharge notification to legal representative, reason or reasons for the discharge, the actions taken by the facility to assist the resident in the discharge and relocation process and the resident?s destination (name and address).?
Plan of Correction:	FACILITY'S RESPONSE: "1. Steps to correct non-compliance with the standard Res #3 discharge statement was updated to include date of discharge notification to legal representative, reason or reasons for discharge, actions taken by the facility to assist then resident with discharge and relocation process and the resident?s destination 2. Measures to prevent the non-compliance from occurring again Discharge statements will have all required sections completed and form signed by ED. BOM will audit form to ensure all sections completed. 3. Person responsible for implementing each step or monitoring any preventative measures"
Standard #:	22VAC40-73-460-A
Description:	Based on the review of facility records and interviews conducted the facility failed to assume general responsibility for the health, safety and well-being a resident. EVIDENCE: Resident #3. Documented date of admission 04/10/2021. Documented date of discharge 07/28/2021. ? The facility assessed the resident on 04/10/2021 as having appropriate behaviors. The facility?s assessments dated 05/28/2021 noted the resident to be a wanderer. On 07/23/2021 facility staff assessed the resident as having aggressive behaviors weekly or more. The assessments note that the resident is disoriented to all spheres all of the time. Facility records submitted for the inspectors? review contained documentation that revealed, that at the time of admission the facility was aware that resident #3 had behavioral disorders that caused, or continue to cause, concern for the health, safety, or welfare of either the applicant or others who could be placed at risk of harm. ? Beginning 04/12/2021; less than a month in care, to date of discharge facility staff documented that the resident engaged in repeated and increased acts of wandering; of the resident attempting to pull out the Foley catheter, of the residents? wife reporting the resident to have increased confusion. On 06/07/2021 facility staff documented on the Progress Notes document ?Resident's wife alerted concierge that while she was in the bathroom, resident left the apartment and she was not able to find him. On another occasion facility staff responded to a call requesting assistance on 3rd floor. Resident #3 had pushed emergency call bell at elevator. Facility staff documented that the resident appears agitated, scowling and with heavy breathing. Pacing the floor and pulling on door knob attempting to enter other resident apartments. Facility staff documented the resident?s wife stating that ?she only turned her head for a second and the resident had left his assigned room and was seen by facility staff just standing at the elevator. For approximately 4 months the facility allowed the resident to remain in care at the facility without documented evidence that (1) facility staff understood the assessment process for placement, (2) that resident #3 had been reassessed to determine appropriateness of placement or an alternative placement, (3) that direct care staff were provided guidance on implementing a plan for increased supervision (4) that a structured plan of care had been developed that established guidance for direct care staff to implement that would ensure that potential and continued aggressive behaviors had no negative impact on the health, safety and well-being of the resident; other residents as well as facility staff. On 07/21/2021 resident #3 attacked resident #5 requiring resident #5 to be sent out for from the facility for emergency medical intervention.
Plan of Correction:	FACILITY'S RESPONSE: "1. Steps to correct the non-compliance with the standard Resident #3 no longer resides at the community Current residents residing on AL will have their UAIs reviewed to determine if a change in behavior has been noted. Appropriate documentation review will be completed, and ISP updated as appropriate. 2. Measures to prevent the non-compliance from occurring again Current Nursing Management team will be re-educated to 22VAC40-73-460. The ED/designee will review UAIs prior to signing to review for changes in behavior to ensure appropriate interventions are on the ISP and that staff training has occurred. 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"