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. 12, 2023

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: On 09/29/2023 Approximate time:10:39a.m-3:45p.m. On 10/11/2023 Approximate time 10:50a.m-5:10p.m. On 10/12/2023 Approximate time 9:40a.m-4:30p.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: 114 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 6 Observations by licensing inspector: Medication pass observed 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 Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that each staff person submitted the results of the annual risk assessment and documented that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The facility records submitted for the inspector?s revealed the following: Facility staff #4-Documented date for TB-07/07/2023; Facility staff #5-Documented date for TB-03/31/2023 Facility records submitted for the inspector?s review did not contain documentation that facility staff #s 4 and 5 did not contain documentation that an annual TB risk assessment was conducted.
Plan of Correction:	FACILITY'S RESPONSE: "Facility will conduct of audit of current employees to ensure compliance. Facility will establish yearly date for make up PPD screenings in addition to conducting TB screening with annual performance evaluation."
Standard #:	22VAC40-73-325-A
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that by the time the comprehensive ISP is completed, a written fall risk rating was completed. Evidence: Resident # 1-Documented date of admission 01/12/2023 Upon request the facility did not submit for the inspector?s review documented evidence that a fall risk rating had been conducted for the resident within 30 day or since admission
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-B
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that the Uniform Assessment Instrument (UAI)s for private pay individuals was completed by a qualified assessor. Evidence: Facility records that was submitted for the inspector?s review noted that the 06/26/2023 UAI reassessment for resident #2 is not signed; the signature lines are blank
Plan of Correction:	FACILITY'S RESPONSE: "Facility will conduct monthly audit of residents to ensure UAI have proper assessor signature." Responsible: Clinical Director/Designee
Standard #:	22VAC40-73-450-D
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that When hospice care is provided to a resident, the assisted living facility and the licensed hospice organization communicated and established an agreed upon coordinated plan of care for the resident. The services provided by each must be included on the individualized service plan (ISP). Evidence: Resident #3 While the resident?s ISP with a date identified as 09/12/2023 notes hospice services is being provided, the ISP does not identify the agreed upon days and timeframes that hospice is to be provided. Resident #4 The resident?s ISP with an identified of 09/14/23 does not note the agreed upon days and timeframes that hospice services will be provided
Plan of Correction:	FACILITY'S RESPONSE: "Facility to conduct audit of current hospice residents to ensure that days and timeframes that hospice is to be provided are noted on ISPs." Responsible: Clinical Director/Designee
Standard #:	22VAC40-73-450-E
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that residents Individualized service plans (ISP) were signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: #2: The resident?s ISP with an initiated date of 07/03/2023 that was submitted for the inspector?s review is not signed or dated; the signature lines are blank. Resident #3: The resident?s ISP with an initiated date of 09/12/2023 that was submitted for the inspector?s review is not signed or dated; the signature lines are blank. Resident #4: The resident?s ISP with an initiated date of 08/08/2023 that was submitted for the inspector?s review is not signed or dated; the signature lines are blank. Resident #5: The resident?s ISP with an initiated date of 08/09/2023 that was submitted for the inspector?s review is not signed or dated; the signature lines are blank. Resident #8: The resident?s ISP with an initiated date of 07/12/2023 that was submitted for the inspector?s review is not signed or dated; the signature lines are blank
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 with facility staff the facility failed to ensure that residents Individualized service plans (ISP) were updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #5- The facility?s October 2023 dietician report for the resident notes the resident to have near significant weight loss. The resident?s 08/09/2023 ISP that was submitted for the inspector?s review is not documented to identify that a plan of care has been developed to address the resident?s ongoing weight loss
Plan of Correction:	FACILITY'S RESPONSE: "Facility to review diet changes daily to ensure recommendations have been communicated to the facility provider. Facility to quarterly meetings with provider to ensure compliance with diet orders." Responsible: Clinical Director/Designee