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. 19, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

Technical assistance offered to facility staff to clarify issues which led to violations of regulations during this inspection. The Licensing Inspector reviewed the following standards with provider: 22VAC 40-73-70-A; 330-A; 450-H; 460-A.

Comments:

An unannounced complaint investigation was initiated on 10/19/2021 and concluded on 11/05/2021. While onsite on 10/19/2021 and 10/20/2021 the facility's Director of Nursing and director of the facility's safe and secure environment were made aware of the complaint. The facility administrator was contacted via email on 10/20/2021 and was emailed a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed medication administration records, nurses? notes, and other facility documentation submitted by the facility to ensure documentation was complete. 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. The exit interview on 10/20/2021 included the facility?s Regional Director of Clinical Services 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. Photographs taken while on site on 10/20/2021 were reviewed with the Director of Nursing before the inspection concluded. 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. If you have any questions I can be reached at (804- 840-0253 or angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on the review of facility records 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: Resident #2-Documented date of admission 08/23/2021 Facility documentation submitted for the inspector?s review revealed that on 09/07/2021 the resident became physically aggressive during activities of daily living (ADL) care resulting in injury to a staff person. A Westmont at Short Pump Progress Notes document charting for 09/10/2021 that was submitted for the inspectors? review notes ?Spoke with Rp (identified) - updates of the day given, also discussed medication administration errors noted today. With the lower dose 0.25 mg of the Lorazepam being given at bedtime vs 0.5mg. RP understanding, informed of new medication orders?. The facility did not make a report regarding either of these incidents about resident #2 to the department.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-330-A
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that a mental health screening was 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. Evidence: Resident #2 Documented date of admission 08/23/2021 Facility records submitted for the inspector?s review did not include a mental health screening prior to admission of resident #2. Upon admission the facility admitted the resident to the safe and secure environment. The resident?s physician responded Yes to the question on the resident?s 08/23/2021 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. A Westmont at Short Pump Progress Notes document charting for 08/30/2021 that was submitted for the inspectors? review notes ?Spoke with Rp about his behaviors, she was also made aware of his broken bed she did say he had the behaviors at home? An 11/04/2021 facility?s self-reported resident incident noted a second incident when the resident?s aggression caused injury to an individual in the facility.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-H
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident. Evidence: Resident #1 Documented date of admission 08/09/2021 The facility?s Westmont Independent Living, Assisted Living, and Memory Care Community document dated 08/05/2021 notes that the resident is confused/disoriented, unable to follow commands and is nonverbal. The resident?s 09/09/2021 Individualized Service Plan (ISP) notes in part on page 1/6 under the heading Interventions ?Use alternative communication tools as needed?. The resident?s ISP is not documented to identify any alternative form of communicating with the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-A
Complaint related:	Yes
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 #2 Documented date of admission 08/23/2021-Upon admission the resident was admitted to the facility?s safe and secure environment. The facility?s Westmont at Short Pump Progress Notes document that was submitted for the inspectors? review revealed that beginning 08/23/2021; day of admission to 11/04/2021- facility Licensed Health Care Professionals and other facility staff documented that the resident engaged in repeated and increased acts of physical aggression and agitation towards other residents and facility staff. The document also noted incidents of the resident?s combativeness during activities of daily living (ADL) care as well as combative behavior when staff attempted to redirect the resident. Facility staff documented the following: 08/23/2021: ?Exit seeker and wander, wanders into other rooms, will take food from other resident's plate. Resistant to redirection?. 08/30/2021: Facility staff documented that at the start of the shift the resident was seen walking around in a brief with stool on the brief and on his shirt and that the resident was walked to his room. Facility staff further documented ?In the room, the resident fought with writer and med tech, blocking the door pushing staff on the bed causing the bed to break, cursing, grabbing arms.yelling and attempted to spit.? 8/31/2021: ?Resident is resistant to redirection, wandering in and out of other resident's rooms family members complaining, staff unable to redirect or get resident to sit down?. 09/02/2021: ?Resident consumed half of breakfast and then walked up to the other residents in the dining room hovering over them with a scowl on his face?. 09/24/2021: ?Wandered in another room, got in the bed with another resident sleeping, became combative, agitated, yelling and cursing when redirected. He was removed from the room x 2 assist and taken to his room where he continued to fight, curse, spit and yell at staff?. 10/20/2021: The Westmont at Short Pump Progress Notes document revealed "Late entry for 10/13/2021- nursing staff notified writer that the resident was seen urinating in the doorway of room (identified) and (room identified) after being toileted by the staff. It was recorded that the resident has a history of urinating on or in different places?. 11/04/2021: A facility?s self-reported resident incident noted that the resident ?became physically and aggressively violent towards the staff possible causing harm to the staff member?. For four months beginning August 2021 to present the facility allowed the resident to remain in care on the safe and secure unit of the facility without documented evidence that (1) the resident had been reassessed to determine appropriateness of placement or an alternative placement, (2) that direct care staff were provided guidance on implementing a plan for increased supervision and (3) that a structured plan of care had been developed that supported the residents? ability of maintaining the highest level of independence or that established guidance for direct care staff to implement that would ensure that the aggressive behaviors had no further negative impact on the health, safety and well-being of the resident; other residents on the safe and secure unit.
Plan of Correction:	Not available online. Contact Inspector for more information.