Inspection Reports for
The Westmont at Short Pump
14399 N. Gayton Road, GLEN ALLEN, VA, 23059
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Inspection Reports Summary
Covers 20 inspections · Mar 2021 – May 2025Visit Reason
This report covers 20 inspections of The Westmont at Short Pump from March 5, 2021 to May 22, 2025, including complaint and routine inspections.
Complaint Details
Multiple complaint surveys were conducted, with investigations supporting some allegations of non-compliance in areas including resident care, administration, staffing, and additional requirements for facilities caring for adults with serious cognitive impairments. Some complaints resulted in violation notices and plans of correction.
Findings
Across that history VDSS cited 55 violations under 38 distinct standards. 12 inspections were prompted by a complaint.
Violations (47)
22VAC40-73-40-A: Licensee failed to ensure compliance with all regulations, laws, and facility policies.
22VAC40-73-1090-A: Facility failed to provide a completed assessment for placement in the special care unit.
22VAC40-73-100-F: Facility failed to follow VDH recommendations to prevent/control infectious agent transmission.
22VAC40-73-1100-A: Facility failed to obtain written approval for placement in special care unit prior to placement.
22VAC40-73-460-A: Facility failed to assume general responsibility for residents' health, safety, and well-being.
22VAC40-73-440-B: Facility failed to ensure UAI for private pay individuals was completed by qualified assessor.
22VAC40-73-250-D: Facility failed to ensure staff submitted annual TB risk assessment documentation.
22VAC40-73-450-E: Facility failed to ensure residents' ISPs were signed and dated by responsible persons.
22VAC40-73-450-F: Facility failed to ensure residents' ISPs were updated at least annually and as needed.
22VAC40-73-450-D: Facility failed to ensure hospice care plan was coordinated and included in ISP.
22VAC40-73-325-A: Facility failed to ensure fall risk rating was completed by time comprehensive ISP done.
22VAC40-73-210-E: Facility failed to ensure training relevant to population was provided by qualified individual.
22VAC40-73-640-A: Facility failed to ensure timely filling/refilling of residents' medications to avoid missed doses.
22VAC40-73-40-A: Licensee failed to ensure compliance with facility's own policies and procedures.
22VAC40-73-220-B: Facility failed to obtain, review, and notify regarding private duty personnel services in writing.
22VAC40-73-210-A: Facility failed to ensure direct care staff attended at least 18 hours of annual training.
22VAC40-73-120-A: Facility failed to ensure orientation and training occurred within first seven working days.
22VAC40-73-680-E: Facility failed to provide medical procedures/treatments ordered by physician as documented.
22VAC40-73-550-G: Facility failed to ensure annual review of resident rights was conducted with staff.
22VAC40-73-620-B: Facility failed to report dietitian recommendations to resident's physician with documentation.
22VAC40-73-440-F: Facility failed to ensure UAI was completed within 90 days prior to admission or after change.
22VAC40-73-440-H: Facility failed to reassess resident after significant change in condition.
22VAC40-73-530-A: Facility failed to provide freedom of movement; locked resident inside room.
22VAC40-73-450-D: Facility failed to ensure hospice care plan was coordinated and included in ISP.
22VAC40-73-325-C: Facility failed to review and update fall risk analysis after a fall.
22VAC40-73-450-C: Facility failed to complete comprehensive ISP within 30 days after admission.
22VAC40-73-70-A: Facility failed to report major incident to licensing office within 24 hours.
22VAC40-73-450-A: Facility failed to develop preliminary plan of care within seven days prior to admission.
22VAC40-73-650-A: Facility failed to ensure no medication or treatment started/changed without valid order.
22VAC40-73-680-I: Facility failed to document medication errors or omissions in resident MARs.
22VAC40-73-150-C: Administrator failed to be responsible for general administration and management.
22VAC40-73-560-B: Facility failed to ensure resident records are identified and easily located.
22VAC40-73-440-B: Facility failed to ensure UAI for private pay individuals was completed by qualified assessor.
22VAC40-73-460-A: Facility failed to assume general responsibility for residents' health, safety, and well-being.
22VAC40-73-220-B: Facility failed to obtain, review, and notify regarding private duty personnel services in writing.
22VAC40-73-450-E: Facility failed to ensure residents' ISPs were signed and dated by responsible persons.
22VAC40-73-450-F: Facility failed to ensure residents' ISPs were updated at least annually and as needed.
22VAC40-73-325-A: Facility failed to ensure fall risk rating was completed by time comprehensive ISP done.
22VAC40-73-210-E: Facility failed to ensure training relevant to population was provided by qualified individual.
22VAC40-73-640-A: Facility failed to ensure timely filling/refilling of residents' medications to avoid missed doses.
22VAC40-73-40-A: Licensee failed to ensure compliance with facility's own policies and procedures.
22VAC40-73-220-B: Facility failed to obtain, review, and notify regarding private duty personnel services in writing.
22VAC40-73-210-A: Facility failed to ensure direct care staff attended at least 18 hours of annual training.
22VAC40-73-120-A: Facility failed to ensure orientation and training occurred within first seven working days.
22VAC40-73-680-E: Facility failed to provide medical procedures/treatments ordered by physician as documented.
22VAC40-73-550-G: Facility failed to ensure annual review of resident rights was conducted with staff.
22VAC40-73-620-B: Facility failed to report dietitian recommendations to resident's physician with documentation.
Report Facts
Violations cited: 55
Distinct standards: 38
Inspections on page: 20
Inspections with violations: 10
Complaint visits: 12
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