Virginia DSS · Assisted Living Facility

The Westmont at Short Pump

📍 14399 N. Gayton Road, Glen Allen, VA, 23059

ID 46837Two Year licenseActive
20
Inspections
On record
10
With violations
Visits that cited something
10
Clean visits
Nothing cited
55
Violations cited
Individual findings
38
Standards cited
Distinct rules
12
Complaint visits
Prompted by a complaint

The Westmont at Short Pump was inspected 20 times between March 5, 2021 and May 22, 2025 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 10 with none. Across that history VDSS cited 55 violations under 38 distinct standards. 12 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 18 of these 20 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
10/31/2026
Administrator
Matthew Hartwick
Licensing inspector
Coy Stevenson
Inspector phone
(804) 972-4700
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

20

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 22, 2025Complaint survey0 violations
Inspection dates
05/22/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: An on-site inspection was conducted on May 22, 2025, from approximately 1:00 PM and 1:30 PM A complaint was received by VDSS Division of Licensing on December 31, 2024, regarding allegations in the area(s) of: Personal care services; Resident accommodations Number of interviews conducted with staff: 1 Additional Comments/Discussion: The resident whom the allegations were in reference to was no longer a resident of the facility at the time of the on-site review. The resident in question moved from the facility on March 31, 2025. Therefore, the allegations related to the conditions of the resident’s room and care provided to the resident could not be assessed. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2025Complaint survey0 violations
Inspection dates
05/22/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: An on-site inspection was conducted on May 22, 2025, from approximately 1:00 PM and 1:45 PM A complaint was received by VDSS Division of Licensing on December 02, 2024, regarding allegations in the area(s) of: Personal care services; Health care services Number of interviews conducted with staff: 2 Additional Comments/Discussion: The resident whom the allegations were in reference to was no longer a resident of the facility at the time of the on-site review. The resident in question passed away November 25, 2024. The facility documented wellness checks on the resident leading up to their hospitalization on November 24, 2024. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 23, 2024Complaint survey5 violations
Inspection dates
12/23/2024
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: 12/23/2024 (arrival 10:30 a.m. / departure 1:45 p.m.), 1/16/2025 (arrival 9:25 a.m. / departure 4:41 p.m.) and 1/29/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. VIRGINIA DEPARTMENT OF SOCIAL SERVICES DIVISION OF LICENSING PROGRAMS INSPECTION SUMMARY (ASSISTED LIVING FACILITY) Facility Name: Westmont at Short Pump Inspection Date: 12/23/2025, 1/16/2025, and File #: 1104903 1/29/2025 DBA: Inspection End Date: ___________________________________________________________________________________________ Page 2 of 3 A complaint was received by VDSS Division of Licensing on 12/20/2024 regarding allegations in the area(s) of: Administration and Administrative Services, Staffing and Supervision, Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:5 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services, Resident Care and Related Services, and Additional Requirements for Facilities That Care for Adults With Serious Cognitive Impairments A violation notice was issued; any violation(s) not related to the complaint(s) 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov 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: 12/23/2024 (arrival 10:30 a.m. / departure 1:45 p.m.), 1/16/2025 (arrival 9:25 a.m. / departure 4:41 p.m.) and 1/29/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/20/2024 regarding allegations in the area(s) of: Administration and Administrative Services, Staffing and Supervision, Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:5 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services, Resident Care and Related Services, and Additional Requirements for Facilities That Care for Adults With Serious Cognitive Impairments A violation notice was issued; any violation(s) not related to the complaint(s) 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on review of facility documentation, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures.
Evidence
  1. (1) Per the facilities Infection Control Policies and Procedures- Resident Health- Policy Number 104 is as follows… POLICY: All newly admitted residents are screened upon admission for communicable disease. All in house residents if suspected or known to have communicable disease will be monitored and treated as ordered by the physician in order to reduce environmental risk. PROCEDURE: …(5) Suspected infectious communicable disease are to be reported as required by the state and local health department. (6) Sudden or unusual outbreaks of serious or uncommon disease will be reported immediately by phone to the local health office. Report results and recommendations by the local health officer will be followed. (2) On November 22, 2024, progress notes for resident #1 noted resident has swelling and redness to right leg. On November 26, 2024, the facility submitted an incident report for resident #1, to the licensing inspector (LI), that the resident was sent to the hospital and admitted due to a change of condition. The facility did not report resident #1’s suspected infections communicable disease to the local health department per the facilities policy. (3)On December 14, 2024, the facility submitted an incident report for resident #2 to the LI that reported resident #2 had a stage II sacrum. The facility did not report resident #2’s suspected infections communicable disease to the local health department the facilities policy.
Plan of correction
Not published by VDSS.
22VAC40-73-1090-A
Based on record review, the facility failed to provide a completed assessment for placement in the special care unit (SCU).
Evidence
  1. The record for resident #3 did not include a dated assessment for placement in the SCU. Resident #3 was admitted into the SCU on November 16, 2022 and the assessment was not dated by the physician. Facility staff #1 was not able to provide the date of the assessment for placement in the SCU.
Plan of correction
Resident chart has been updated to include physician signature and date. The Executive Director and Director of Clinical Services, or designee, will ensure that all residents in our special care unit have physician approval for placement prior to placement. The community will conduct a quarterly audit to ensure compliance with this standard.
22VAC40-73-100-F
Based on review of the resident records and facility documentation, the facility failed to follow the Virginia Department of Health recommendations to prevent or control transmission of an infectious agent in the facility.
Evidence
  1. On August 7, 2024, the Richmond and Henrico Health Districts (RHHD) began an investigation on the first reported case of Group A Streptococcus (GAS) at the facility. Correspondence between the local public health department and facility on December 19, 2024 detailed a continuing outbreak at the facility and the facility’s failure to report subsequent soft skin issues as requested by the local health department in October 2024 correspondence to the facility. (2) On October 16, 2024, RHHD advised the facility of upcoming screening they would do on both staff and residents for GAS, and provided background information to the facility as to the many different types of infections GAS can cause to include skin and soft tissue infections. (3) On November 22, 2024, progress notes for resident #1 noted “resident has swelling and redness to right leg”, and that the resident stated that “it felt tight and gave her a slight limp”. (4) On November 24, 2024, resident #1’s progress notes noted that resident #1’s left lower leg noted to have 2 open areas with white scab on top…right leg remains red and swollen. The facility did not report resident # 1’s suspected infections communicable disease to the local health department per the facilities policy. (5) On December 14, 2024, the facility submitted an incident report for resident #2 to the LI that reported resident #2 had a stage II sacrum. The facility did not report resident # 2’s suspected infections communicable disease to the local health department per the facilities policy.
Plan of correction
Not published by VDSS.
22VAC40-73-1100-A
Based on review of resident records, the facility failed to obtain written approval for placement in the special care unit prior to placement.
Evidence
  1. The record for resident #4 documented the resident was admitted into the SCU on November 7, 2022, and the approval for placement was dated January19, 2023, after the resident’s placement in the SCU.
  2. Staff #1 confirmed the date of the approval for placement in the special care unit.
Plan of correction
This omission of documentation was discovered through our internal audit process. It was corrected on 1/19/2022. The Executive Director and Director of Clinical Services, or designee, will ensure that all residents in our special care unit will have necessary approval documentation completed prior to placement. The community will conduct a quarterly audit to ensure compliance with this standard.
22VAC40-73-460-A
Based on a documentation review and interviews conducted with facility staff the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. On 12/19/2024, the licensing office received a complaint report related to the care of residents and an infectious disease outbreak at the facility. Recommendations were made by the local health department in relation to the future spread of disease.
  2. Based on documentation review and interviews with staff #1 the facility failed to protect the health and well-being of the residents by not reporting subsequent residents’ skin and soft tissue issues to the Virgina Department of Health to prevent the spread of Streptococcal disease, Group A.
Plan of correction
Not published by VDSS.
October 18, 2024Inspection0 violations
Inspection dates
10/18/2024
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: On 10/18/2024 approximate time 11:00-1:50p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 09/30/2024 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: N/A Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed residents during lunch time meal Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 20, 2024Inspection0 violations
Inspection dates
09/20/2024
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 09/20/2024 Approximate time 10:32am-4:27p.m. On 10/18/2024 approximate time 11:00a.m-1:50p.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: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Observation of noon time meal and medication administration conducted on 09/20/2024. Additional Comments/Discussion: Resident and staff interviews initiated on 09/20/2024 and concluded on 10/18/2024. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 11, 2023Complaint survey0 violations
Inspection dates
10/11, 12/2023
Comments
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/11/2023-Approximate time 10:51a.m-5:11p.m. 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. A complaint was received by VDSS Division of Licensing on 09/15/2023 regarding allegations in the Resident Care and Related Services and Staffing and Supervision. 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: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 29, 2023Inspection6 violations
Inspection dates
09/29/2023, 10/11, 12/2023
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
22VAC40-73-440-B
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
  1. 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
22VAC40-73-250-D
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
Evidence
  1. d 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."
22VAC40-73-450-E
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
  1. #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 published by VDSS.
22VAC40-73-450-F
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
  1. 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
22VAC40-73-450-D
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
  1. 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
22VAC40-73-325-A
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
  1. 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 published by VDSS.
September 29, 2023Complaint survey0 violations
Inspection dates
09/29/2023, 10/11,12/2023
Comments
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/29/2023-Approximate time10:39a.m-3:14p.m On 10/11/2023-Approximate time 10:51a.m-5:11p.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. A complaint was received by VDSS Division of Licensing on 08/22/2023 regarding allegations in the areas of Resident Care and Related Services and Staffing 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: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 31, 2023Complaint survey0 violations
Inspection dates
05/31/2023
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.m-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 by VDSS Division of Licensing on 03/13/2023 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 116 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: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 31, 2023Complaint survey4 violations
Inspection dates
05/31/2023
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
22VAC40-73-210-E
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
  1. 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 published by VDSS.
22VAC40-73-640-A
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
  1. 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 published by VDSS.
22VAC40-73-40-A
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
  1. 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 published by VDSS.
22VAC40-73-220-B
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
  1. 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 published by VDSS.
October 27, 2022Inspection5 violations
Inspection dates
10/27/2022, 10/28/2022, 11/04/2022
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
22VAC40-73-210-A
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
  1. 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."
22VAC40-73-120-A
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
  1. 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."
22VAC40-73-680-E
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
  1. 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. "
22VAC40-73-550-G
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
22VAC40-73-620-B
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
  1. 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."
May 23, 2022Complaint survey0 violations
Inspection dates
05/23/2022
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: 05/23/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/23/2022 regarding allegations in the areas of medication administration. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 31, 2022Complaint survey8 violations
Inspection dates
03/31/2022, 04/01/2022, 04/30/2022
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
22VAC40-73-450-F
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
  1. 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 published by VDSS.
22VAC40-73-450-C
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
  1. 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 published by VDSS.
22VAC40-73-70-A
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
  1. 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 published by VDSS.
22VAC40-73-450-A
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
  1. 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 published by VDSS.
22VAC40-73-440-F
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
  1. 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 published by VDSS.
22VAC40-73-440-H
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 published by VDSS.
22VAC40-73-530-A
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
  1. 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 published by VDSS.
22VAC40-73-450-D
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
  1. 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 published by VDSS.
March 29, 2022Complaint survey1 violation
Inspection dates
03/29/2022, 03/31/2022
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 11:01 a.m. until 4:00 p.m; On 03/31/2022 between the approximate time of 12:51p.m until 2:08p.m The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were 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
22VAC40-73-70-A
Based on the review of facility records and interviews conducted with facility staff 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
  1. Resident #1-Documented date of admission The review of facility records and interviews conducted with facility staff on 03/29/2022 revealed the following: Resident #1 had a fall at the facility on 03/27/2022 during the 11-7 shift change that required outside emergency medical intervention. Due to the injuries sustained the resident was admitted to the hospital. The facility did not submit an incident report regarding this matter until 04/04/2022.
Plan of correction
Not published by VDSS.
March 29, 2022Inspection7 violations
Inspection dates
03/29/2022, 03/31/2022, 04/01/2022, 04/30/2022
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
22VAC40-73-325-C
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
  1. 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 published by VDSS.
22VAC40-73-450-C
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
  1. 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 published by VDSS.
22VAC40-73-450-A
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
  1. 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 published by VDSS.
22VAC40-73-370
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
  1. 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 published by VDSS.
22VAC40-73-325-B
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
  1. 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 published by VDSS.
22VAC40-73-70-A
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
  1. 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 published by VDSS.
22VAC40-73-450-F
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
  1. 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 published by VDSS.
March 29, 2022Complaint survey8 violations
Inspection dates
03/29/2022, 03/31/2022, 04/01/2022, 04/30/2022
Comments
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 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) 840-0253 or by email at angela.r.reaves@dss.virginia.gov@dss.virginia.gov
Violations
22VAC40-73-650-A
Based on the review of facility records and interviews conducted the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment is started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. Resident #1- Documented date of admission 05/17/2021 The complainant alleges that on three separate occasions facility staff had to collect urine from resident #1 because the urine collected per physician’s orders on 02/21/2022 and 02/23/2022 were both collected but never processed. The third physician’s order for urine collection was written on 04/27/2022. The resident’s physician’s orders charting for 01/01/2022-05/31/2022 that was submitted for the inspector’s review in part noted the following orders: 02/21/2022: “collect urine (2/21) for UA and C&S and send in am (2/22) for evaluation. one time only for R41.82 for 3 Days”. The document also notes that the order was started on 02/21/2022 and completed on 02/24/2022. 02/23/2022: “Recollect urinalysis and culture (R45.1) as well as CBC, BMP next lab day (Dx: F03.90) one time only for Entered monitoring for 3 Days.”- The order was started on 03/23/2022 and completed on 02/26/2022. 02/23/2022: Responding to the resident’s 02/21/2022 physician’s order to collect a urine sample- the facility’s nurse practitioner noted on the facility’s progress notes document “Will need to be recollected. Please do NOT collect from pure wick container please have patient void. Labs also ordered.” 04/27/2022: “send urine on 4/27 for UA and C&S (R31.9) one time Prescriber only for collect and send urine for culture (hematuria) for 3 days- order started on 04/27/2022 and was completed on 04/30/2022. . 04/27/2022: Order 04/27/2022; Started 04/27/2022 and completed 0n 04/30/2022. 04/27/2022: “Urine collected in fridge in med room.” 04/28/2022: N.O. for UA with Culture, please update RP the lab req has been completed and in the lab book. 05/06/2022: In an email exchange with the complainant, facility staff #1 stated “I received documentation that the urine sample was collected and picked up from the lab this morning! I will keep an eye and pulse on the results and let you know as soon as I can.”
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on the review of facility records and interviews conducted the facility failed to ensure that resident medication administration records (MARs) were documented to reflect any medication errors or omissions.
Evidence
  1. Resident #1- Documented date of admission 05/17/2021 The facility MARs charting for March, April and May 2022 revealed multiple dates that facility staff did not document whether the resident was administered the prescribed medications. For example: ' March 2022 03/20/2022: LORazepam Tablet 1930 1 MG Give 1 tablet by mouth in the evening for anxiety ' April 2022: 04/12, 22, 26, 27/2022: Miralax Give 17 gram by mouth one time a day for constipation mix one capful 04/22, 26/2022: Senna Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth in 'e morning every 2 day(s) for Constipation. 04/22/2022: Diclofenac Potassium Tablet50MG Give 1 tablet by mouth two times a day for OA-at 9:00a.m 04/22/2022: levETIRAcetam Solution 100 MG/ML Give 7 .5 ml by mouth two times a day for SEIZURES-at 9:00a. 04/22/2022: Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth two times a day for PAIN 04/24/2022: Desltln Paste 40 % to be applied at 9:00a.m 04/27, 28 30/2022: LORazepam Tablet 1 MG Give 1 tablet by mouth In the evening for anxiety
Plan of correction
Not published by VDSS.
22VAC40-73-150-C
Based on the review of facility records and interviews conducted with the facility staff, the Administrator failed to be responsible for the general administration and management of the facility and shall oversee the day-to-day operation of the facility. This shall include responsibility for: 1-Ensuring that care is provided to residents in a manner that protects their health, safety, and well-being. 6-supervising staff
Evidence
  1. Resident #1- Documented date of admission 05/17/2021 ' Beginning 04/24/2022 thru 05/20/2022 notes emails on file at the department and documented concerns from the complainant to the facility Administrator and or facility staff #s 1, 2 and 3 informing of concerns reported to the facility regarding whether the resident’s prescribed mechanical soft diet was being offered based on the selections chosen, ADL care not being provided per the resident’s care plan and concerns regarding medication administration. ' 04/26/2022 the complainant reported “They will not return my emails or even call me about bringing in (resident #1 identified) doctor.” 05/23/2022: Responding to the inspector’s inquiry during the telephone interview whether the resident’s chosen daily meal plan was being provided; the facility Administrator said he did not know and that the dietary department would handle that. ' 04/30/2022: During the telephone interview the inspector made the Administrator aware that allegations of abuse and neglect had been made against facility staff. On 05/23/2022 during a follow up telephone interview the facility Administrator stated that he had never been made aware of the allegations regarding lack of care and privacy violations during ADL care. ' March 2022: Medication prescribed for seizure activity is not being consistently administered. ' 05/20/2022: An email from the complainant to facility staff #1 that is on file at the department notes “I also asked you on our phone call last night, for the second time, for you or facility staff #3(identified) to look at (resident #1 identified) medications to make sure they were in the cart and properly dosed, and not running out! I would like verification that this has been done.” 05/23/2022: Responding to the inspector’s inquiry during the telephone interview of whether an incident report had been made to the regional licensing office informing that beginning 05/13-18/2022 facility staff did not administer by mouth at bedtime the 2 MG/ML 0.5 ml of the medication Lorazepam to resident #1 and whether the medication management plan was being followed-the Administrator stated that he was aware but was waiting on facility staff #1 to submit the report. The facility Administrator did not submit upon request documented evidence demonstrating that follow up inquiries from the complainant regarding the resident’s care have been responded to or that the Administrator is providing supervision to facility staff ensuring that the resident’s assessed needs are being consistently implemented.
Plan of correction
Not published by VDSS.
22VAC40-73-220-B
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
  1. Resident #1: documented date of admission 05/17/2021 Facility records submitted for the inspector’s review via email on 05/20/2022 notes facility private sitter documentation dated 05/22/2022 for two different individuals. Upon request 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 published by VDSS.
22VAC40-73-450-H
Based on the review of facility records the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident,
Evidence
  1. Resident #1: documented date of admission 05/17/2021 The resident’s ISP dated 10/29/2021 that was submitted for the inspector’s review notes that the facility documented that the resident uses “Bunny Boots to bilateral feet at night to decrease skin breakdown. The facility’s progress notes documents charting for May 2022 that was submitted for the inspector’s review notes that on 10 different occasions facility staff documented that the “Boots are misplaced, no bunny boots found” indicating that the identified service need of resident #1 was not provided to the resident.
Plan of correction
Not published by VDSS.
22VAC40-73-70-A
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
  1. Resident #1-Documented date of admission 05/17/2021 The complainant reported that beginning 05/13/2022 thru 05/18/2022 resident #1 was not administered Lorazepam concentrate-0.5 ml by mouth at bedtime for anxiety. The facility Administrator stated during a 05/23/2022 telephone interview that he was aware of the matter. As of 06/23/2022 an incident report has not been submitted.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
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
  1. Resident #1-Documented date of admission 05/17/2021 The facility’s Medication Management & Service Policy Number 800A with an effective date of 11/02/2018 that was submitted for the inspector’s review via email on 05/23/2022 notes under the heading -Methods to ensure 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: “Only authorized Community staff may reorder medications from the Pharmacy. The Community staff should review all on-demand medications daily and re-order when a 5-day supply of the medication is remaining. Emergency refills must be called to the Pharmacy. The community should indicate the date and time the medication is needed.” ' The resident’s physician order charting for 01/01/2022-05/31/2022 notes “Lorazepam Concentrate- 2 MG/ML. Give 0.5 ml.by mouth at bedtime for anxiety. From 05/13/2022 thru 05/18/2022 facility staff documented on the resident’s MAR indicating that resident #1 was not administered the medication. Multiple facility staff also noted on the facility’s progress notes document that the medication was “on order “and “on order need new script.” 05/13 @19:15 : LORazepam Concentrate 2 MG/ML Give 0.5 ml by mouth at bedtime for anxiety on order nn/a 05/14 @ 19:44 on order need new script 05/15 @ 20:33 med n/a waiting for refill 05/16 @ 21:20 on order 05/17 @ 20:11 on order 05/18 @ @ 21:05 on order ' The facility’s nurse’s notes document charting for March, April and May 2022 that was submitted for the inspectors’ review note the following: 03/06-08/2022: Cephalexin Tablet 250 MG Give 250 mg by mouth in the evening (at1700) for recurrent UTI “Med not available Rx notified to refill and send”. 03/09/2022: Cephalexin Capsule 250 MG Give 1 capsule by mouth in the evening (at 1800) for recurrent UTI “waiting medication from pharmacy” For 4 days the resident was not administered the medication Cephalexin as prescribed. 04/28, 29, 30/2022: Lorazepam Tablet 1 MG -Give 1 tablet by mouth in the evening for anxiety “Med not available”. 05/01, 02/2022: Lorazepam Tablet 1 MG -Give 1 tablet by mouth in the evening for anxiety Med “not available” For three days the resident was not the medication Lorazepam as prescribed.
Plan of correction
Not published by VDSS.
22VAC40-73-560-B
Based on the review of facility records and interviews conducted the facility failed to ensure that resident records are identified and easily located by resident name, including when a resident's record is kept in more than one place. This shall apply to both electronic and hard copy material.
Evidence
  1. Resident #1: documented date of admission 05/17/2021 On 05/20, 23/2022 via email to the facility Administrator and facility staff #1 the inspector requested the following facility documentation but did not receive: ' Facility documentation confirming that a report was made to Henrico adult protective services regarding the alleged aggressive behavior of facility staff during resident ADL care on 03/26/2022 during the 7-3 shift and on 04/17/2022-lack of privacy during ADL care. The facility responded in part via email on 05/23/2022- “Please note that we are still awaiting historical documentation that was requested from 03/26/2022 and 04/17/2022.” As of 06/02/2022 the facility has not responded whether documentation exist or not. ' The facility’s documentation of all weights recorded for August, September and October 2021. Via email on 05/20/2022 the facility only submitted the resident’s weight for October 2021. ' The complete MARs and exception pages beginning 03/01/ 2022 to present. The facility submitted the MARs for April and May 2022 but did not submit documentation of the 03/01/2022 to present MARs that notes the reasons medications were not administered, or whether facility staff administered the medications late.
Plan of correction
Not published by VDSS.
October 19, 2021Complaint survey4 violations
Inspection dates
10/19/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Technical assistance
Technical assistance offered to facility staff to clarify issues which led to violations of regulations during this inspection. The Licensing Inspector reviewed the following standards with provider: 22VAC 40-73-70-A; 330-A; 450-H; 460-A.
Comments
An unannounced complaint investigation was initiated on 10/19/2021 and concluded on 11/05/2021. While onsite on 10/19/2021 and 10/20/2021 the facility's Director of Nursing and director of the facility's safe and secure environment were made aware of the complaint. The facility administrator was contacted via email on 10/20/2021 and was emailed a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed medication administration records, nurses’ notes, and other facility documentation submitted by the facility to ensure documentation was complete. An exit interview was conducted on both days with the Director of Nursing for assisted living and the director of the facility’s safe and secure environment. The exit interview on 10/20/2021 included the facility’s Regional Director of Clinical Services where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The facility Administrator was not on site at the facility on 10/19, 20/2021. Photographs taken while on site on 10/20/2021 were reviewed with the Director of Nursing before the inspection concluded. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. If you have any questions I can be reached at (804- 840-0253 or angela.r.reaves@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on the review of facility records and interviews conducted the facility failed to assume general responsibility for the health, safety and well-being a resident.
Evidence
  1. Resident #2 Documented date of admission 08/23/2021-Upon admission the resident was admitted to the facility’s safe and secure environment. The facility’s Westmont at Short Pump Progress Notes document that was submitted for the inspectors’ review revealed that beginning 08/23/2021; day of admission to 11/04/2021- facility Licensed Health Care Professionals and other facility staff documented that the resident engaged in repeated and increased acts of physical aggression and agitation towards other residents and facility staff. The document also noted incidents of the resident’s combativeness during activities of daily living (ADL) care as well as combative behavior when staff attempted to redirect the resident. Facility staff documented the following: 08/23/2021: “Exit seeker and wander, wanders into other rooms, will take food from other resident's plate. Resistant to redirection”. 08/30/2021: Facility staff documented that at the start of the shift the resident was seen walking around in a brief with stool on the brief and on his shirt and that the resident was walked to his room. Facility staff further documented “In the room, the resident fought with writer and med tech, blocking the door pushing staff on the bed causing the bed to break, cursing, grabbing arms.yelling and attempted to spit.” 8/31/2021: “Resident is resistant to redirection, wandering in and out of other resident's rooms family members complaining, staff unable to redirect or get resident to sit down”. 09/02/2021: “Resident consumed half of breakfast and then walked up to the other residents in the dining room hovering over them with a scowl on his face”. 09/24/2021: “Wandered in another room, got in the bed with another resident sleeping, became combative, agitated, yelling and cursing when redirected. He was removed from the room x 2 assist and taken to his room where he continued to fight, curse, spit and yell at staff”. 10/20/2021: The Westmont at Short Pump Progress Notes document revealed "Late entry for 10/13/2021- nursing staff notified writer that the resident was seen urinating in the doorway of room (identified) and (room identified) after being toileted by the staff. It was recorded that the resident has a history of urinating on or in different places”. 11/04/2021: A facility’s self-reported resident incident noted that the resident “became physically and aggressively violent towards the staff possible causing harm to the staff member”. For four months beginning August 2021 to present the facility allowed the resident to remain in care on the safe and secure unit of the facility without documented evidence that (1) the resident had been reassessed to determine appropriateness of placement or an alternative placement, (2) that direct care staff were provided guidance on implementing a plan for increased supervision and (3) that a structured plan of care had been developed that supported the residents’ ability of maintaining the highest level of independence or that established guidance for direct care staff to implement that would ensure that the aggressive behaviors had no further negative impact on the health, safety and well-being of the resident; other residents on the safe and secure unit.
Plan of correction
Not published by VDSS.
22VAC40-73-70-A
Based on the review of facility records 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
  1. Resident #2-Documented date of admission 08/23/2021 Facility documentation submitted for the inspector’s review revealed that on 09/07/2021 the resident became physically aggressive during activities of daily living (ADL) care resulting in injury to a staff person. A Westmont at Short Pump Progress Notes document charting for 09/10/2021 that was submitted for the inspectors’ review notes “Spoke with Rp (identified) - updates of the day given, also discussed medication administration errors noted today. With the lower dose 0.25 mg of the Lorazepam being given at bedtime vs 0.5mg. RP understanding, informed of new medication orders”. The facility did not make a report regarding either of these incidents about resident #2 to the department.
Plan of correction
Not published by VDSS.
22VAC40-73-450-H
Based on the review of facility records and interviews conducted the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident.
Evidence
  1. Resident #1 Documented date of admission 08/09/2021 The facility’s Westmont Independent Living, Assisted Living, and Memory Care Community document dated 08/05/2021 notes that the resident is confused/disoriented, unable to follow commands and is nonverbal. The resident’s 09/09/2021 Individualized Service Plan (ISP) notes in part on page 1/6 under the heading Interventions “Use alternative communication tools as needed”. The resident’s ISP is not documented to identify any alternative form of communicating with the resident.
Plan of correction
Not published by VDSS.
22VAC40-73-330-A
Based on the review of facility records and interviews conducted the facility failed to ensure that a mental health screening was conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.
Evidence
  1. Resident #2 Documented date of admission 08/23/2021 Facility records submitted for the inspector’s review did not include a mental health screening prior to admission of resident #2. Upon admission the facility admitted the resident to the safe and secure environment. The resident’s physician responded Yes to the question on the resident’s 08/23/2021 Report of Resident Physical Examination document that within the previous six months the resident has exhibited behaviors that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. A Westmont at Short Pump Progress Notes document charting for 08/30/2021 that was submitted for the inspectors’ review notes “Spoke with Rp about his behaviors, she was also made aware of his broken bed she did say he had the behaviors at home” An 11/04/2021 facility’s self-reported resident incident noted a second incident when the resident’s aggression caused injury to an individual in the facility.
Plan of correction
Not published by VDSS.
October 6, 2021Inspection7 violations
Inspection dates
10/06/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Technical assistance
Technical assistance offered to facility administrator to clarify issues which led to violations of regulations during this inspection. The Licensing Inspector reviewed the following standards with provider: 22VAC 40-73-40-B; 220; 325-A; 325-B; 325-C; 330-A; 330-B; 430-H; 440-B; 460-A; 650-A; 680-I
Comments
An unannounced renewal inspection was initiated on 10/06/2021. The facility administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 79. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, medication administration records, nurses’ notes, and other facility documentation submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/19, 20/2021. An exit interview was conducted on both days with the Director of Nursing for assisted living and the director of the facility’s safe and secure environment where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The facility Administrator was not on site at the facility on 10/19, 20/2021. The exit interview conducted on 10/20/2021 also included a representative from the facility’s regional clinical team who was on site at the facility. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions I can be reached at (804z0 840-0253 or angela.r.reaves@dss.virginia.gov
Violations
22VAC40-73-430-H-1
Based on the review of facility records the facility failed to ensure that at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contained all of the required elements.
Evidence
  1. Resident #3-Documented date of discharge 07/28/2021 The resident’s discharge document (state model form) that was submitted for the inspector’s review is blank in the sections requesting: “The date of discharge notification to legal representative, reason or reasons for the discharge, the actions taken by the facility to assist the resident in the discharge and relocation process and the resident’s destination (name and address).”
Plan of correction
FACILITY'S RESPONSE: "1. Steps to correct non-compliance with the standard Res #3 discharge statement was updated to include date of discharge notification to legal representative, reason or reasons for discharge, actions taken by the facility to assist then resident with discharge and relocation process and the resident’s destination 2. Measures to prevent the non-compliance from occurring again Discharge statements will have all required sections completed and form signed by ED. BOM will audit form to ensure all sections completed. 3. Person responsible for implementing each step or monitoring any preventative measures"
22VAC40-73-220-A
Based on the review of facility records the facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, that all requirements were met.
Evidence
  1. Resident #3- Documented date of admission 04/10/2021. Documented date of discharge 07/28/2021. Resident #4 Documented date of admission-07/27/2021 Facility records submitted for the inspector’s review notes that resident #s 3 and 4 received the services of a private duty individual while in care at the facility. Upon request the facility did 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(s) by private duty personnel, reviewed the information to determine if it is acceptable, and provided notification to the home care organization regarding any needed changes.
Plan of correction
FACILITY'S RESPONSE: "1. Steps to correct the non-compliance with the standard Resident #3 no longer resides in the community Resident # 4 no longer has private duty personnel An audit will be completed to ensure that all required information for private duty personnel is in place. 2. Measures to prevent the non-compliance from occurring again Current nursing management will be re-educated to 22VAC40-73-220A regarding private duty personnel. Wellness Director/Director of Inspiritas Clinical and Engagement/designee will audit all residents with private duty personnel 2 times a month to ensure current accurate information regarding private duty services being provided. 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
22VAC40-73-325-C
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
  1. Resident #4 Documented date of admission-07/27/2021 The facility’s Progress Notes document and the Morse Fall-Senior Living (assessment) documented dated 08/02/2021 for the resident revealed that a fall occurred while in care at the facility. Upon request the facility did not submit for the inspector’s review documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of correction
FACILITY'S RESPONSE: " 1. Steps to correct the non-compliance with the standard Resident falls with be reviewed weekly at resident risk meeting weekly 2. Measures to prevent the non-compliance from occurring again Current nursing management team will be re-educated to 22VAC40-73-325-C. Wellness Director/Director of Inspiritas Clinical and Engagement/designee will review all falls to ensure that there is documented analysis of the circumstances of the fall and interventions were initiated to prevent or reduce the risk of subsequent falls 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
22VAC40-73-330-B
Based on the review of facility records and interviews conducted the facility failed to ensure that a mental health screening was conducted when a resident displays behaviors or patterns of behavior indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders that cause concern for the health, safety, or welfare of either that resident or others who could be placed at risk of harm by the resident. Resident #3 Documented date of admission-04/10/2021. Documented date of discharge 07/28/2021. Facility records submitted for the inspector’s review revealed the following: 07/23/2021: The facility submitted a self-reported incident to the department informing that on 07/22/2-21 (resident #3 identified) “pushed resident #5 onto the floor and during the fall hit her head on an end table. Police arrived to assess the situation and speak to (resident #3 identified). Facility documentation also noted that the residents’ personal care aide was present when the incident occurred. 08/02/2021: A follow up report from the facility regarding this matter notes under the heading Outcome of Incident: “(Resident #5 identified) returned to community from ED no new orders received”. (Resident #3 identified) returned to with admission to secure Memory care Unit”. The document also notes that resident #3 was admitted to the facility’s safe and secure environment with 24 hour private care aide. The facility admitted the resident to the safe and secure environment without documentation that a mental health screening was conducted after the aggressive altercation with another resident.
Plan of correction
FACILITY'S RESPONSE: "1. Steps to correct non-compliance with the standard Resident #3 no longer resides in the community Current AL residents will be re-evaluated for any behaviors or patterns of behaviors. Any residents identified will be referred to the community mental health professional. 2. Measures to prevent the non-compliance from occurring again Current nursing management team will be re-educated to VAC40-73-330-B Wellness Director/Director of Inspiritas Clinical and Engagement/designee will review documentation weekly to identify behaviors or patterns of behaviors with appropriate referral to mental health documented 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
22VAC40-73-40-B-12
Based on the review of facility records the facility failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in § 63.2-1706 of the Code of Virginia.
Evidence
  1. Resident #3- Documented date of admission 04/10/2021. Documented date of discharge 07/28/2021. Upon request the facility did not submit for the inspector’s review the facility's documentation of approval and appropriateness of placement on the facility’s safe and secure unit and facility documentation for the residents receiving private duty services. Resident #4-Documented date of admission 07/27/2021. Facility records submitted for the inspector’s review revealed that upon admission the residents’ personal care aide was with the resident. Upon request the facility did not submit for the inspectors’ documentation that while in care the resident was receiving private duty services and what the specific services were. The facility also did not submit upon request documentation that prior to being placed in charge, facility staff #5 was informed of and received training on the duties and responsibilities and provided written documentation of such duties and responsibilities.
Plan of correction
FACILITY'S RESPONSE: "1. Steps to correct non-compliance with the standard: (I would make this more of a statement: Community will allow representative opportunity to inspect documents/facilities as necessary 2. Measures to prevent the non-compliance from occurring again Prior to any resident having private duty personnel in the community, the community will be provided with all required information regarding what specific services the private duty personnel will be providing. Prior to any team member being in charge in the community, they will have documented training on the duties and responsibilities of being in charge. 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
22VAC40-73-460-A
Based on the review of facility records and interviews conducted the facility failed to assume general responsibility for the health, safety and well-being a resident.
Evidence
  1. Resident #3. Documented date of admission 04/10/2021. Documented date of discharge 07/28/2021. • The facility assessed the resident on 04/10/2021 as having appropriate behaviors. The facility’s assessments dated 05/28/2021 noted the resident to be a wanderer. On 07/23/2021 facility staff assessed the resident as having aggressive behaviors weekly or more. The assessments note that the resident is disoriented to all spheres all of the time. Facility records submitted for the inspectors’ review contained documentation that revealed, that at the time of admission the facility was aware that resident #3 had behavioral disorders that caused, or continue to cause, concern for the health, safety, or welfare of either the applicant or others who could be placed at risk of harm. • Beginning 04/12/2021; less than a month in care, to date of discharge facility staff documented that the resident engaged in repeated and increased acts of wandering; of the resident attempting to pull out the Foley catheter, of the residents’ wife reporting the resident to have increased confusion. On 06/07/2021 facility staff documented on the Progress Notes document “Resident's wife alerted concierge that while she was in the bathroom, resident left the apartment and she was not able to find him. On another occasion facility staff responded to a call requesting assistance on 3rd floor. Resident #3 had pushed emergency call bell at elevator. Facility staff documented that the resident appears agitated, scowling and with heavy breathing. Pacing the floor and pulling on door knob attempting to enter other resident apartments. Facility staff documented the resident’s wife stating that “she only turned her head for a second and the resident had left his assigned room and was seen by facility staff just standing at the elevator. For approximately 4 months the facility allowed the resident to remain in care at the facility without documented evidence that (1) facility staff understood the assessment process for placement, (2) that resident #3 had been reassessed to determine appropriateness of placement or an alternative placement, (3) that direct care staff were provided guidance on implementing a plan for increased supervision (4) that a structured plan of care had been developed that established guidance for direct care staff to implement that would ensure that potential and continued aggressive behaviors had no negative impact on the health, safety and well-being of the resident; other residents as well as facility staff. On 07/21/2021 resident #3 attacked resident #5 requiring resident #5 to be sent out for from the facility for emergency medical intervention.
Plan of correction
FACILITY'S RESPONSE: "1. Steps to correct the non-compliance with the standard Resident #3 no longer resides at the community Current residents residing on AL will have their UAIs reviewed to determine if a change in behavior has been noted. Appropriate documentation review will be completed, and ISP updated as appropriate. 2. Measures to prevent the non-compliance from occurring again Current Nursing Management team will be re-educated to 22VAC40-73-460. The ED/designee will review UAIs prior to signing to review for changes in behavior to ensure appropriate interventions are on the ISP and that staff training has occurred. 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
22VAC40-73-330-A
Based on the review of facility records the facility failed to ensure that a mental health screening is conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Resident #3 Documented date of admission-04/10/2021. Documented date of discharge 07/28/2021. The resident’s physician responded Yes to the question on the resident’s 03/16/2021 Report of Resident Physical Examination document that within the previous six months the resident has exhibited behaviors that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. The resident was assessed by facility on 04/10/2021, 05/28/2021 and 07/23/2021 as not needing a psychiatric or psychological evaluation. The 05/28/2021 UAI assessment document was also signed by the facility Administrator.
Plan of correction
FACILITY'S RESPONSE: "1. Steps to correct the non-compliance with the standard Resident #3 no longer resides in the community 2. Measures to prevent the non-compliance from occurring again Residents admitted to the community with documentation on their H&P of Yes to the question on that within the last 6 months the resident has exhibited behaviors that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and the caused or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk will be referred to the community mental health provider if the resident does not have their own mental health provider. 3. Person responsible for implementing each step or monitoring any preventative measures Wellness Director/Director of Inspiritas Clinical and Engagement/ED"
May 13, 2021Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 05/13/2021 and concluded on 06/30/2021. The licensing inspector emailed the administrator a list of documentation required to complete the inspection. The evidence gathered during the inspection determined compliance with applicable standards or laws. The facility Administrator reported that the current census was 18. The inspector reviewed two resident records, two staff records, and other facility documentation and facility policy etc. submitted by the facility to ensure documentation was complete. If you have any questions please feel free to contact me at (804) 662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 5, 2021Inspection0 violations
Areas reviewed
22VAC40-73 BUILDING AND GROUNDS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. An initial inspection was initiated on 03/05/2021 and concluded on 03/31/2021. The facility Administrator was contacted by via an email to initiate the inspection. The inspector emailed a representative for the licensee a list of items specific items required to determine that the initial application was complete. Inspector reviewed the initial application components, the Disclosure Statement for the facility, some policies and procedures and floor plans. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. A Conditional license is recommended.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.