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: May 31, 2023

Complaint Related: Yes

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/31/2023 between the approximate times of 9:40 a.m3 ? 5:04 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received at the department on 12/12/2022 regarding allegations in the areas of administrative services, personnel and resident care and related services. 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: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 5 Observations by licensing inspector: No obvious concerns noted. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law. A violation notice was 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

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility administrative staff the licensee failed to ensure compliance with the facility's own policies and procedures. EVIDENCE: Resident #1. Documented date of admission 06/30/2021 Documented date of discharge 05/20/2023 The facility?s Disclosure Statement on file at the department notes in part on pg. 6/9 under the heading ?Criteria for discharge from the facility, including actions, circumstances, or conditions that would result or may result in discharge of the resident: ?Significant decline in functioning such that the community can no longer appropriately take care of the resident.? The facility?s Nurse Practitioner?s assessment documentation that was submitted for the inspector?s review regarding resident #1 revealed the following under the heading ?Establish care, Huntington?s disease:? ? 07/02/2022: ?She does have a fair degree of chorea and cognitive decline, often limiting her care and ADLs. She is currently WC bound and unable to feed herself. We discussed that her disease process may lead her to need a higher level of care sooner rather than later if not now as she requires too much care for the ALF staff setting. ? 11/21/2022: ?She is not able to use the call bell to ask for help and discussed 2 options with family ? pt will require higher level of care such as a SNF or she will require 24 hour sitter service for safety.? ? 11/22/2022: Email correspondence on file at the department between the facility and the residents power of attorney in part notes ?As your well aware (resident #1 identified) needs rounds the clock supervision. We are not able to provide that in a ALF setting. We have gotten to the point of her not being safe alone.? ? The facility?s Progress Note document that was submitted for the inspector?s review revealed that the resident?s nurse practitioner documented her assessment on 12/05/2022 that the resident needed 24 hr sitter/supervision due to physical limitations/fall concerns; that the resident?s falls are more frequent with lacerations/injury, that the resident ?is not able to consistently ring call bell for help when falling? and that her assessment of skilled nursing placement for resident #1 versus sitter services was discussed with the resident?s family and facility administration. ? Facility records identify resident #1 as a high risk for falls and also notes that the resident has had multiple falls with injuries that required outside emergency medical intervention: 12/1/22; 12/11/22 and12/24/2022. Resident #1 remained in care at the facility eleven months after the nurse practitioner?s documented assessment of the resident?s decline. Upon request the facility did not submit for the inspector?s review documented evidence that a nursing home assessment for possible placement was conducted.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-E
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility administrative staff the facility failed to ensure that the training required is relevant to the population in care and must be provided by a qualified individual through in-service training programs or institutes, workshops, classes, or conferences. EVIDENCE: Resident #1. Documented date of admission: 06/30/2021 Documented date of discharge: 05/20/2023 During staff interviews conducted on 05/31/2023 the current facility Administrator stated that she could not locate any documentation that facility direct care staff has obtained training regarding Huntington?s Disease.
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: 06/30/2021 Documented date of discharge: 05/20/2023 A former facility Administrator noted in an email dated 01/23/2023 ?The Westmont does not have any documentation on file of a private sitter agreement. We have requested clarification on this person and if they are in fact a private sitter?. Upon request while on site at the facility on 05/31/2023 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 #:	22VAC40-73-640-A
Complaint related:	No
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: 06/30/2021 Documented date of discharge: 05/20/2023 The facility?s Progress Notes document and Medication Administration Records charting for December 2022, February 2023 and January 2023 that was submitted for the inspector review noted various entries of ?Meds not available, Med not on cart Reordered, On order, Waiting on Pharmacy? for the following medications: ? 150 mg of the medication Venlafaxine to be administered- 2 tablet by mouth one time a day for depression was not administered on: 12/20/2022; 01/24,25/2023 and 02/14,15,23/2023. ? 500mg of the medication Bacitracin Zinc ointment to be applied to head topically two times a day for head injury for 5 days was not applied once on 12/24/2022; twice on 12/25, 26/2022 and once on 12/28/2022. ? 50mg of the medication Myrbetriq tablet to be administered one time a day for urinary was not administered on 12/29,30,31/2022; 01/02-06/2023 and 02/09,11,12,15/2023. ? 0.5mg tablet of the medication ClonazePAM to be administered two times a day related to Huntington disease was not administered on 01/15, 16/2023; 02/25/2023. ? 1/20 mg of the medication JunelFE 1/2 tablet to be administered one time a day for cycle management was not administered 02/07, 8/2023. ?
Plan of Correction:	Not available online. Contact Inspector for more information.