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: No

Comments:

The inspector was onsite at the facility on the following days to conduct an unannounced non-mandated follow up inspection: 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 inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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

Violations:

Standard #:	22VAC40-73-70-A
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 06/30/2021 During interviews conducted on 04/01/2022 facility direct care staff reported two separate incidents involving resident #1 that were not reported to the regional licensing office. Facility staff stated during interviews that on 03/20/2022 the resident was burned on her lip and neck trying to pick up and drink a hot cup of coffee that a dietary staff sat in front of her. Facility staff further reported that due to the resident?s medical diagnosis the resident is not able to grasp items such as a cup. Facility staff also reported that on 03/29/2022 while the residents? service provider was pushing the resident #1 in her wheelchair the resident simultaneously fell out of the wheel chair. The facility?s Progress Notes document confirmed both incidents and also noted that each time the resident fell out of her wheel chair the seat belt was not in use. The facility did not submit the required reports for these two resident incidents until 04/04/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-B
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 #1 Documented date of admission-06/30/2021 Facility staff #1 noted on the facility?s Progress notes document that resident #1 had a fall with injury on 03/28/2022. The facility did not ensure that a fall risk assessment was conducted regarding the resident?s 03/28/2022 fall with injury.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-C
Description:	Based on the review of facility records the facility failed to ensure that the fall risk analysis was reviewed and updated after a fall. Evidence: Resident #1 Documented date of admission-06/30/2021 The facility?s Progress Notes document dated 03/29/2022 and the Morse Fall-Senior Living (assessment) documented dated 02/10, 18, 26/2022 for the resident revealed that falls occurred. Upon request the facility did not submit documentation that analysis of the circumstances of the fall and that interventions were initiated to prevent or reduce the risk of subsequent falls regarding the falls that occurred on 02/10, 18, 26/2022 and 03/29/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-370
Description:	Based on the review of facility records the facility failed to ensure that the ISP for a respite resident was completed prior to the person participating in respite care. Evidence: Resident #3-Documented date of admission 03/24/2022 The resident?s Individualized service plan (ISP) is signed and dated by facility staff #1 on the resident?s date of admission and not prior to admission as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care (ISP) was developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #5- Documented date of admission-03/23/2022 The resident?s preliminary ISP 03/23/2022 identifies resident #5 as being at a high risk for falls with the resident?s goal documented as the resident ?will be more aware of fall hazards and avoid them and ask for assistance.? The resident?s 03/15/2022 Report of Resident Physical Examination document note that the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The facility?s documented expectation that the resident will be able to protect her own safety contradicts the physician?s diagnosis. The resident?s preliminary ISP was not developed based on the resident?s assessed needs. The facility?s Westmont Independent Living, Assisted Living, and Memory Care Community document dated 03/15/2022 and signed by a physician notes ?Teeth brushing with water flosser at bedtime. The resident?s 03/23/2022 ISP does not identify this order from the doctor as a need.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on the review of facility records and interviews conducted the facility failed to identify a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them. Evidence: Resident #1-Documented date of admission 06/30/2021 Upon request to review the most recent Individualize Service Plan (ISP) for resident #1 the facility submitted a 08/21/2021 ISP noting that Physical therapy, Occupational therapy and Speech language pathology were identified as a need for the resident on 09/09/2021. For each of the service providers identified facility staff noted on the ISP under the heading Interventions ?evaluate and treat?. Resident #3-Documented date of admission 03/24/2022 The resident?s most recent ISP dated 03/24/2022 notes Physical therapy and Occupational therapy as an identified on 03/25/2022. ISP notes under the heading Interventions ?evaluate and treat?. The ISPs for resident #s 1 and 3 is not documented to identify the specific delivery of services for the residents regarding evaluate and treat.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that Individualized service plans(ISP) are reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #6- Facility records revealed a physician?s order for a raised toilet seat dated 12/13/2021. The resident?s 10/20/2021 ISP is not documented to identify the raised toilet seat as a need.
Plan of Correction:	Not available online. Contact Inspector for more information.