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: March 29, 2022 , March 31, 2022 , April 1, 2022 and April 30, 2022

Complaint Related: Yes

Comments:

On 03/29/2022 between the approximate time of 11:012 a.m. until 4:00p.m; 03/31/2022 between the approximate time of 12:51p.m until 2:08p.m 04/01/2022 between the approximate time of 7:54a.m until 3:39p.m 04/30/2022 between the approximate time of 7:40p.m until 12:21p.m The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted 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 #1-Documented date of admission 05/17/2021 The complainant reported that beginning 05/13/2022 thru 05/18/2022 resident #1 was not administered Lorazepam concentrate-0.5 ml by mouth at bedtime for anxiety. The facility Administrator stated during a 05/23/2022 telephone interview that he was aware of the matter. As of 06/23/2022 an incident report has not been submitted.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-150-C
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with the facility staff, the Administrator failed to be responsible for the general administration and management of the facility and shall oversee the day-to-day operation of the facility. This shall include responsibility for: 1-Ensuring that care is provided to residents in a manner that protects their health, safety, and well-being. 6-supervising staff Evidence: Resident #1- Documented date of admission 05/17/2021 ' Beginning 04/24/2022 thru 05/20/2022 notes emails on file at the department and documented concerns from the complainant to the facility Administrator and or facility staff #s 1, 2 and 3 informing of concerns reported to the facility regarding whether the resident?s prescribed mechanical soft diet was being offered based on the selections chosen, ADL care not being provided per the resident?s care plan and concerns regarding medication administration. ' 04/26/2022 the complainant reported ?They will not return my emails or even call me about bringing in (resident #1 identified) doctor.? 05/23/2022: Responding to the inspector?s inquiry during the telephone interview whether the resident?s chosen daily meal plan was being provided; the facility Administrator said he did not know and that the dietary department would handle that. ' 04/30/2022: During the telephone interview the inspector made the Administrator aware that allegations of abuse and neglect had been made against facility staff. On 05/23/2022 during a follow up telephone interview the facility Administrator stated that he had never been made aware of the allegations regarding lack of care and privacy violations during ADL care. ' March 2022: Medication prescribed for seizure activity is not being consistently administered. ' 05/20/2022: An email from the complainant to facility staff #1 that is on file at the department notes ?I also asked you on our phone call last night, for the second time, for you or facility staff #3(identified) to look at (resident #1 identified) medications to make sure they were in the cart and properly dosed, and not running out! I would like verification that this has been done.? 05/23/2022: Responding to the inspector?s inquiry during the telephone interview of whether an incident report had been made to the regional licensing office informing that beginning 05/13-18/2022 facility staff did not administer by mouth at bedtime the 2 MG/ML 0.5 ml of the medication Lorazepam to resident #1 and whether the medication management plan was being followed-the Administrator stated that he was aware but was waiting on facility staff #1 to submit the report. The facility Administrator did not submit upon request documented evidence demonstrating that follow up inquiries from the complainant regarding the resident?s care have been responded to or that the Administrator is providing supervision to facility staff ensuring that the resident?s assessed needs are being consistently implemented.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-220-B
Complaint related:	No
Description:	Based on the review of facility records the facility failed to ensure that when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, the requirements listed under subdivisions A 2 through A 6 of this section apply. In addition, before direct care or companion services are initiated, the facility shall: Obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, review the information to determine if it is acceptable, and provide notification to whomever has hired the private duty personnel regarding any needed changes. Evidence: Resident #1: documented date of admission 05/17/2021 Facility records submitted for the inspector?s review via email on 05/20/2022 notes facility private sitter documentation dated 05/22/2022 for two different individuals. Upon request the facility did not 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 by private duty personnel, reviewed the information to determine if it is acceptable, and provide notification to whomever has hired the private duty personnel regarding any needed changes.
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 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 05/17/2021 The resident?s ISP dated 10/29/2021 that was submitted for the inspector?s review notes that the facility documented that the resident uses ?Bunny Boots to bilateral feet at night to decrease skin breakdown. The facility?s progress notes documents charting for May 2022 that was submitted for the inspector?s review notes that on 10 different occasions facility staff documented that the ?Boots are misplaced, no bunny boots found? indicating that the identified service need of resident #1 was not provided to the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-B
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that resident records are identified and easily located by resident name, including when a resident's record is kept in more than one place. This shall apply to both electronic and hard copy material. Evidence: Resident #1: documented date of admission 05/17/2021 On 05/20, 23/2022 via email to the facility Administrator and facility staff #1 the inspector requested the following facility documentation but did not receive: ' Facility documentation confirming that a report was made to Henrico adult protective services regarding the alleged aggressive behavior of facility staff during resident ADL care on 03/26/2022 during the 7-3 shift and on 04/17/2022-lack of privacy during ADL care. The facility responded in part via email on 05/23/2022- ?Please note that we are still awaiting historical documentation that was requested from 03/26/2022 and 04/17/2022.? As of 06/02/2022 the facility has not responded whether documentation exist or not. ' The facility?s documentation of all weights recorded for August, September and October 2021. Via email on 05/20/2022 the facility only submitted the resident?s weight for October 2021. ' The complete MARs and exception pages beginning 03/01/ 2022 to present. The facility submitted the MARs for April and May 2022 but did not submit documentation of the 03/01/2022 to present MARs that notes the reasons medications were not administered, or whether facility staff administered the medications late.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on the review of facility records and interview conducted the facility failed to implement a written plan that ensured that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: Resident #1-Documented date of admission 05/17/2021 The facility?s Medication Management & Service Policy Number 800A with an effective date of 11/02/2018 that was submitted for the inspector?s review via email on 05/23/2022 notes under the heading -Methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages: ?Only authorized Community staff may reorder medications from the Pharmacy. The Community staff should review all on-demand medications daily and re-order when a 5-day supply of the medication is remaining. Emergency refills must be called to the Pharmacy. The community should indicate the date and time the medication is needed.? ' The resident?s physician order charting for 01/01/2022-05/31/2022 notes ?Lorazepam Concentrate- 2 MG/ML. Give 0.5 ml.by mouth at bedtime for anxiety. From 05/13/2022 thru 05/18/2022 facility staff documented on the resident?s MAR indicating that resident #1 was not administered the medication. Multiple facility staff also noted on the facility?s progress notes document that the medication was ?on order ?and ?on order need new script.? 05/13 @19:15 : LORazepam Concentrate 2 MG/ML Give 0.5 ml by mouth at bedtime for anxiety on order nn/a 05/14 @ 19:44 on order need new script 05/15 @ 20:33 med n/a waiting for refill 05/16 @ 21:20 on order 05/17 @ 20:11 on order 05/18 @ @ 21:05 on order ' The facility?s nurse?s notes document charting for March, April and May 2022 that was submitted for the inspectors? review note the following: 03/06-08/2022: Cephalexin Tablet 250 MG Give 250 mg by mouth in the evening (at1700) for recurrent UTI ?Med not available Rx notified to refill and send?. 03/09/2022: Cephalexin Capsule 250 MG Give 1 capsule by mouth in the evening (at 1800) for recurrent UTI ?waiting medication from pharmacy? For 4 days the resident was not administered the medication Cephalexin as prescribed. 04/28, 29, 30/2022: Lorazepam Tablet 1 MG -Give 1 tablet by mouth in the evening for anxiety ?Med not available?. 05/01, 02/2022: Lorazepam Tablet 1 MG -Give 1 tablet by mouth in the evening for anxiety Med ?not available? For three days the resident was not the medication Lorazepam as prescribed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment is started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: Resident #1- Documented date of admission 05/17/2021 The complainant alleges that on three separate occasions facility staff had to collect urine from resident #1 because the urine collected per physician?s orders on 02/21/2022 and 02/23/2022 were both collected but never processed. The third physician?s order for urine collection was written on 04/27/2022. The resident?s physician?s orders charting for 01/01/2022-05/31/2022 that was submitted for the inspector?s review in part noted the following orders: 02/21/2022: ?collect urine (2/21) for UA and C&S and send in am (2/22) for evaluation. one time only for R41.82 for 3 Days?. The document also notes that the order was started on 02/21/2022 and completed on 02/24/2022. 02/23/2022: ?Recollect urinalysis and culture (R45.1) as well as CBC, BMP next lab day (Dx: F03.90) one time only for Entered monitoring for 3 Days.?- The order was started on 03/23/2022 and completed on 02/26/2022. 02/23/2022: Responding to the resident?s 02/21/2022 physician?s order to collect a urine sample- the facility?s nurse practitioner noted on the facility?s progress notes document ?Will need to be recollected. Please do NOT collect from pure wick container please have patient void. Labs also ordered.? 04/27/2022: ?send urine on 4/27 for UA and C&S (R31.9) one time Prescriber only for collect and send urine for culture (hematuria) for 3 days- order started on 04/27/2022 and was completed on 04/30/2022. . 04/27/2022: Order 04/27/2022; Started 04/27/2022 and completed 0n 04/30/2022. 04/27/2022: ?Urine collected in fridge in med room.? 04/28/2022: N.O. for UA with Culture, please update RP the lab req has been completed and in the lab book. 05/06/2022: In an email exchange with the complainant, facility staff #1 stated ?I received documentation that the urine sample was collected and picked up from the lab this morning! I will keep an eye and pulse on the results and let you know as soon as I can.?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that resident medication administration records (MARs) were documented to reflect any medication errors or omissions. Evidence: Resident #1- Documented date of admission 05/17/2021 The facility MARs charting for March, April and May 2022 revealed multiple dates that facility staff did not document whether the resident was administered the prescribed medications. For example: ' March 2022 03/20/2022: LORazepam Tablet 1930 1 MG Give 1 tablet by mouth in the evening for anxiety ' April 2022: 04/12, 22, 26, 27/2022: Miralax Give 17 gram by mouth one time a day for constipation mix one capful 04/22, 26/2022: Senna Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth in 'e morning every 2 day(s) for Constipation. 04/22/2022: Diclofenac Potassium Tablet50MG Give 1 tablet by mouth two times a day for OA-at 9:00a.m 04/22/2022: levETIRAcetam Solution 100 MG/ML Give 7 .5 ml by mouth two times a day for SEIZURES-at 9:00a. 04/22/2022: Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth two times a day for PAIN 04/24/2022: Desltln Paste 40 % to be applied at 9:00a.m 04/27, 28 30/2022: LORazepam Tablet 1 MG Give 1 tablet by mouth In the evening for anxiety
Plan of Correction:	Not available online. Contact Inspector for more information.