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. 27, 2022 , Oct. 28, 2022 and Nov. 4, 2022

Complaint Related: No

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/27/2022: 12:37p.m-4:10p.m, 10/28/2022=12:14p.m-3:10p.m. and on 11/04/2022: 7:21a.m.-10:35a.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication pass Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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 #:	22VAC40-73-120-A
Description:	Based on the review of facility records the facility failed to ensure that orientation and training required in subsections B and C of this section occurred within the first seven working days of employment. Evidence: Facility staff #1: Documented date of hire 03/15/2021 Facility staff #3: Documented date of hire 08/31/2021 Upon request the facility did not submit for the inspector?s review documentation that facility staff #1 was provided orientation as required.
Plan of Correction:	FACILITY'S RESPONSE: "Facility will do a 100% Audit of all Employee Records to be completed within the next 60 days, and no later than 01-11-23. The two staff identified as not having documented orientation in their employee file will be provided another general orientation, with the completion of such being documented in their file. This will be completed no later than 11-30-2022. To prevent recurrence, all new employee files will be reviewed by both the HR Manager and Executive Director on a weekly basis to ensure that the orientation that must be completed within the first seven days of hire is documented correctly. This will be an ongoing process."
Standard #:	22VAC40-73-210-A
Description:	Direct care staff training. A3 Based on the review of facility records the facility failed to ensure that when a facility licensed for both residential and assisted living care, all direct care staff attend at least 18 hours of training annually. Evidence: Facility staff #1: Documented date of hire 03/15/2021 Facility records submitted for the inspector?s review only noted 4.75 hours of annual training.
Plan of Correction:	FACILITY'S RESPONSE: "Facility will do a 100% Audit of all Employee Records to be completed within the next 60 days, and no later than 01-11-23. The staff identified as not having adequate training hours will be provided with a training schedule to ensure that they receive all the required hours. This training will be logged correctly in their employee file. This will be completed no later than 11-30-2022. To prevent recurrence, training logs will be pulled monthly by the HR Manager to ensure that employees, and their direct supervisors, are notified when required training is due. Noncompliance with the training assignments will result in the employee being removed from the schedule. This will be an ongoing process."
Standard #:	22VAC40-73-550-G
Description:	Based on the review of facility records with the facility Administrator the facility failed to ensure that the annual review of resident rights were conducted with staff. Facility staff #1: Documented date of hire 03/15/2021 Facility staff #2: Documented date of hire 09/23/2021 Upon request the facility did not submit for the inspector?s review documentation that the annual review of residents? rights was conducted with facility staff #s 1 and 2.
Plan of Correction:	FACILITY'S RESPONSE: "Facility will do a 100% Audit of all Employee Records to be completed within the next 60 days, and no later than 01-11-23. All employees will receive a review of Resident Rights, with copies of these reviews being placed in their employee file. This will be completed within the next thirty days; no later than 12-10-22. To prevent recurrence, community will begin having quarterly reviews of the Resident Right?s Agreement. This will be an ongoing process
Standard #:	22VAC40-73-620-B
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that upon receipt of recommendations noted in subdivision 3 of this subsection, the administrator, dietitian, or nutritionist must report them to the resident's physician. Documentation of the report must be maintained in the resident's record. Evidence: Resident #1: Documented date of admission 06/30/2021 The facility?s 10/20/2022 dietician report that was submitted for the inspector?s review recommended that the facility obtain weekly weights on the resident. Upon request the facility did not submit for the inspector?s review documented evidence that the resident?s physician was made aware of the recommendations from the dietician.
Plan of Correction:	FACILITY'S RESPONSE: "An order was obtained by the physician to begin weekly weights as per the recommendation; however, a note was not placed in the progress note section of the chart by the nurse who obtained the order. A late entry of notification was documented to rectify this. This has been corrected. To prevent recurrence, there will be a two-step review of all dietary recommendations. After the assigned nurse completes the recommendations, there will be an audit completed by the Director of Nursing, or designee, to ensure that all interventions are not only completed with orders obtained, but also all communication to the MD and POA about the recommendation is documented appropriately. This will be an ongoing process."
Standard #:	22VAC40-73-680-E
Description:	Medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident's record. Evidence: Resident #1: Documented date of admission 06/30/2021 The resident?s physicians? order dated 11/10/2021 notes ?Monthly weights to be obtained by the 5th of each month?. Upon request the facility did not submit for the inspector?s review documented evidence that weights were obtained for the resident in February, May and June 2022.
Plan of Correction:	FACILITY'S RESPONSE: "All weights July 2022 to current month have been obtained and recorded correctly. To prevent recurrence, Director of Nursing will begin doing weekly, monthly and quarterly weight audits to avoid noncompliance in the future. This process will be ongoing. "