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 31, 2022 , April 1, 2022 and April 30, 2022

Complaint Related: Yes

Comments:

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)

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on interviews conducted with facility staff and the review of facility records the facility failed report an incident to the regional licensing office within 24 hours of 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 07/12/2021 12/30/2021: Facility staff #5 documented that resident #1 was sent out from the facility to a local hospital for emergency medical intervention. Responding to the inspector?s inquiry the facility Administrator reported in part ?Resident had a fall on 12/30/21. Resident did have complaint of left knee and hip pain and was sent for medical attention for further evaluation? As of 05/16/2022 the facility has not submit an incident report to the regional licensing office regarding the 12/30/2021 incident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-F
Complaint related:	No
Description:	Based on interviews conducted with facility staff and the review of facility records the facility failed to ensure that a residents? UAI was completed within 90 days prior to admission to the assisted living facility, except that if there has been a change in the resident's condition since the completion of the UAI that would affect the admission, a new UAI shall be completed. Evidence: Resident #1- Documented date of admission 07/12/2021 The resident?s 07/12/2021 Uniform Assessment Instrument (UAI) document that was submitted for the inspector?s review is also noted as the resident?s documented date of admission. Upon request the facility did not submit for the inspector?s review documented evidence that a change had occurred in the resident's condition since the completion of the 07/12/2021 UAI that would affect the admission, and indicating that a new UAI is needed. The facility also did not provide evidence of any kind clarifying why the resident?s UAI was not conducted within 90 days prior to the resident?s 07/12/2021 admission.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on interviews conducted with facility staff and the review of facility records the facility failed to ensure that a reassessments of a resident was conducted due to a significant change in the resident's condition, to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Resident #1- Documented date of admission 07/12/2021 Facility records submitted for the inspector?s review on 05/12/2022 notes that the resident was not reassessed until 11/18/2021; four months later and noted that the resident needed help with eating/feeding and that staff needed to spoon feed the resident in order to complete this task
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care is developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: Resident #1- Documented date of admission 07/12/2021 Upon request via email to the facility on 04/24/2022 and 05/02/2022 to review the resident?s most recent Individualized Service Plan (ISP) the current facility Administrator submitted an ISP on 05/03/2022 that is dated 07/12/2021; which is also noted as the resident?s date of admission. The document is identified as the resident?s preliminary ISP. The resident?s 07/12/2021 ISP and facility?s Progress Notes documents that were also submitted for the inspector?s review revealed the following: A hospice agreement between the identified hospice agency and the facility was signed by facility staff #3 on 04/01/2021 three months before the resident?s 07/12/2021 date of admission. On 07/15/2021 facility staff documented on the Progress Notes document ?Has been admitted to (hospice agency identified) Comfort Kit delivered.? The hospice agency that facility staff referenced is the same hospice agency that facility staff #3 signed the 04/01/2022 hospice agreement with. The resident?s 04/01/2021 hospice agreement notes under the heading Community Obligations 5.2 ? Individualized Service Plan- ?The plan of care for each resident including a description of services being provided by Hospice and Community shall be documented in the resident?s Individualized Service Plan in accordance with Virginia law and regulations. The Individualized Service Plan shall be signed and dated by hospice and community staff who developed or updated the Individualized service plans?. The resident?s 07/12/2021 ISP was not documented to note the agreed upon services as required in the signed -4/01/2021 hospice agreement. The hospice service was not added to the resident?s ISP until 08/12/2021. The resident?s Do Not Resuscitate (DNR) order is signed 07/15/2021 but is not included on the resident?s ISP until -8/17/2021. Department model form ?Appropriateness of placement and continued residence? that is used by the facility notes the resident?s documented date of admission as 07/12/2021. During the 05/12/2022 telephone interview the facility Administrator confirmed that resident #1 was admitted into the facility?s safe and secure environment on 07/12/2021; date of admission. The resident?s 07/12/2021 preliminary ISP that was submitted for the inspector?s review does not identify the need for a secured environment. The need for placement in the facility?s safe and secure environment was not noted on the resident?s ISP until 08/17/2021. The facility did not develop the preliminary Individualized Service Plan for resident #1 based on the resident?s assessed needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the comprehensive individualized service plan was completed within 30 days after admission that identified the needs of the resident including 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 07/12/2021 The resident?s Do Not Resuscitate order (DNR) that was submitted for the inspector?s review on 05/12/2022 is dated 07/15/2021-three days after the resident was admitted to the facility. The resident?s comprehensive Individualized Service Plan (ISP) that was submitted for the inspector?s review on 05/12/2022 via email from the facility is dated 08/12/2021 and does not identify the resident?s 07/15/2021 Do Not Resuscitate order (DNR) as an identified need.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on interviews conducted with facility staff and the review of facility records the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The facility failed to ensure that the services provided by each is included on the individualized service plan. Evidence: Resident #1- Documented date of admission 07/12/2021 During the 05/12/2022 telephone interview facility staff #2 clarified and the facility Administrator submitted recent Individualized Service Plans (ISP) for resident #1 that are dated 08/12/2021 and 11/18/2021. Upon request the facility submitted to the inspector the resident?s hospice agreement that facility staff referenced on the resident?s 08/12/2021 ISP. However, the hospice agreement submitted by the facility on 05/12/2022 is signed and dated by facility staff #3 on 04/01/2021. The facility did not develop the resident?s 7/12/2021 preliminary ISP to note the 04/01/2021 signed hospice agreement and the services that the facility and hospice agency had agreed upon.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the Individualized service plans was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: Resident #1- Documented date of admission 07/12/2021 Upon request via email to the facility on 04/24/2022 and on 05/02/2022 to review the resident?s most recent Individualized Service Plan (ISP) the current facility Administrator submitted an ISP on 05/03/2022 that is dated 07/12/2021. During the 05/12/2022 telephone interview facility staff #2 clarified that ISPs had been updated for the resident since 07/12/2021 and submitted an ISP dated 08/12/2021 and 11/18/2021. DNR order was not included in the resident?s ISP prior to 11/18/2021-The DNR order was signed on 07/15/2021 Facility records that were submitted for the inspector?s review notes that a hospice agreement was signed on 10/06/2021. The facility did not update the resident?s ISP to note the 10/06/2021 hospice agreement until 11/18/2021. The resident?s 10/06/2021 hospice agreement notes under the heading Community Obligations 5.2 ? Individualized Service Plan ?The plan of care for each resident including a description of services being provided by Hospice and Community shall be documented in the resident?s Individualized Service Plan in accordance with Virginia law and regulations. The Individualized Service Plan shall be signed and dated by hospice and community staff who developed or updated the Individualized service plans?. When hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. The facility did not submit documentation that the resident?s ISPs were being developed and updated in conjunction with the hospice agency as required by the hospice agreement and noted updated to identify all of the resident?s assessed needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-530-A
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to provide freedom of movement for the residents to common areas and to their personal spaces. The facility failed to ensure that no residents were locked out of or inside their rooms. Evidence: Resident #1-Documented date of admission 07/12/2021 Facility records submitted for the inspector?s review notes that resident #1 has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and resides in the facility?s safe and secure environment since 07/12/2021. The complainant alleges that the former facility Administrator gave staff approval to have a lock placed on the resident?s door to keep other residents from wandering into the room. The complainant further alleges that staff then had to call maintenance to unlock the resident door. Once the door was unlocked, staff found the resident sitting in her wheelchair with the lights off and the television on and that the resident is total care- unable to self-propel the wheelchair, or unable to get out of the chair to lock or unlock a door. Interviews conducted with facility staff#1 during the complaint investigation confirmed that in response to a 02/21/2022 work order received from the previous facility Administrator she put a lock on the resident?s bedroom door. The facility?s Work Order document dated 02/21/2022 that facility staff #1 submitted for the inspector?s review notes under the heading Comments: ?put lock on residents door?. Facility staff #1 further stated that on 02/22/2022 she received an order to remove the lock from the door-which she did. Based on facility staff interviews conducted and facility records reviewed the facility locked resident#1 inside her room on 02/21/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.