Inspection Reports for
The Westmont at Short Pump
14399 N. Gayton Road, GLEN ALLEN, VA, 23059
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
113 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 22, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on December 02, 2024, regarding allegations related to personal care services and health care services at the facility.
Complaint Details
Complaint related to personal care services and health care services; the allegations were not substantiated.
Findings
The investigation found that the evidence did not support the allegations of non-compliance with standards or law. The resident involved was no longer at the facility, having passed away prior to the inspection, and the facility documented wellness checks leading up to the resident's hospitalization.
Report Facts
Number of interviews conducted: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 22, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on December 31, 2024, regarding allegations related to personal care services and resident accommodations.
Complaint Details
Complaint related to personal care services and resident accommodations; the resident in question moved from the facility on March 31, 2025. The investigation did not substantiate the allegations.
Findings
The resident referenced in the complaint was no longer at the facility at the time of inspection, so the allegations could not be assessed. The evidence gathered did not support the allegations of non-compliance with standards or law.
Report Facts
Number of interviews conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 5
Date: Jan 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2024-12-20 regarding allegations in the areas of Administration and Administrative Services, Staffing and Supervision, Resident Care and Related Services at the assisted living facility.
Complaint Details
The complaint was substantiated in part; evidence supported some allegations related to administration, resident care, and infection control, but not all allegations were confirmed.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Administration and Administrative Services, Resident Care and Related Services, and Additional Requirements for Facilities That Care for Adults With Serious Cognitive Impairments. Violations included failure to provide completed assessments and approvals for special care unit placement, failure to follow health department recommendations to control infectious disease transmission, and failure to report communicable diseases as required.
Deficiencies (5)
Facility failed to provide a completed assessment for placement in the special care unit (SCU).
Facility failed to obtain written approval for placement in the special care unit prior to placement.
Facility failed to follow Virginia Department of Health recommendations to prevent or control transmission of an infectious agent.
Licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department.
Facility failed to assume general responsibility for the health, safety, and well-being of the residents, including failure to report subsequent residents' skin and soft tissue issues to the Virginia Department of Health.
Report Facts
Number of residents present: 113
Number of resident records reviewed: 5
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Census: 120
Deficiencies: 0
Date: Oct 18, 2024
Visit Reason
The inspection was a monitoring visit conducted on October 18, 2024, following a self-report received on September 30, 2024, regarding allegations in the area of resident care and related services.
Findings
The investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued, and the inspection findings will be posted publicly.
Report Facts
Number of resident records reviewed: 4
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 120
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license, with on-site visits on September 20, 2024, and October 18, 2024.
Findings
The inspection found no violations of applicable standards or laws. Observations included a tour of the physical plant, resident and staff interviews, and observation of meal and medication administration.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 4
Staff interviews conducted: 5
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-09-15 regarding allegations in Resident Care and Related Services and Staffing and Supervision.
Complaint Details
Complaint received on 2023-09-15 regarding Resident Care and Related Services and Staffing and Supervision; allegations were not substantiated.
Findings
The investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued.
Report Facts
Number of residents present: 114
Number of resident records reviewed: 1
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-08-22 regarding allegations in the areas of Resident Care and Related Services and Staffing.
Complaint Details
Complaint received by VDSS Division of Licensing on 2023-08-22 regarding Resident Care and Related Services and Staffing. The allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued.
Report Facts
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
Inspection Report
Renewal
Census: 114
Deficiencies: 6
Date: Oct 12, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found multiple violations related to staff tuberculosis screening, fall risk assessments, Uniform Assessment Instrument completion, hospice care coordination, and individualized service plans including signatures and updates. Violation notices were issued and plans of correction were requested.
Deficiencies (6)
Facility failed to ensure that each staff person submitted the results of the annual risk assessment and documented tuberculosis screening.
Facility failed to ensure that a written fall risk rating was completed by the time the comprehensive ISP is completed.
Facility failed to ensure that the Uniform Assessment Instrument (UAI) for private pay individuals was completed by a qualified assessor.
Facility failed to ensure that when hospice care is provided, the assisted living facility and licensed hospice organization communicated and established an agreed upon coordinated plan of care.
Facility failed to ensure that residents' Individualized Service Plans (ISP) were signed and dated by the licensee, administrator, or designee and by the resident or legal representative.
Facility failed to ensure that residents' Individualized Service Plans (ISP) were updated at least once every 12 months and as needed for significant changes in condition.
Report Facts
Number of residents present: 114
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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Rodgers-Reaves | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Coy Stevenson | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 31, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2022-12-12 regarding allegations in administrative services, personnel, and resident care and related services.
Complaint Details
Complaint was substantiated in part; some allegations were supported by evidence while others were not. A violation notice was issued.
Findings
The investigation supported some but not all allegations of non-compliance. Violations were found related to failure to comply with facility policies, inadequate staff training, failure to properly document private duty personnel services, and failure to ensure timely medication administration.
Deficiencies (4)
Failure to ensure compliance with the facility's own policies and procedures related to resident discharge criteria and care needs.
Failure to ensure training required is relevant to the population in care and provided by qualified individuals.
Failure to obtain, review, and notify regarding private duty personnel services as required.
Failure to implement a written plan ensuring prescription and over-the-counter medications are filled and refilled timely to avoid missed dosages.
Report Facts
Resident records reviewed: 1
Staff interviews conducted: 5
Medication administration failures: 6
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: May 31, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-03-13 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint received on 2023-03-13 regarding resident care and related services; investigation did not substantiate the allegations.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued.
Report Facts
Number of residents present: 116
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Inspection Report
Renewal
Deficiencies: 5
Date: Oct 27, 2022
Visit Reason
The inspection was conducted as a renewal inspection of The Westmont at Short Pump assisted living facility on October 27, 28, and November 4, 2022.
Findings
The inspection found multiple violations related to staff orientation and training, annual review of resident rights, communication of dietary recommendations to physicians, and documentation of medical procedures and treatments. The facility was found non-compliant with applicable standards and laws.
Deficiencies (5)
Failed to ensure orientation and training required within the first seven working days of employment.
Failed to ensure all direct care staff attend at least 18 hours of training annually.
Failed to ensure annual review of resident rights was conducted with staff.
Failed to report dietician recommendations to resident's physician and maintain documentation.
Failed to provide and document medical procedures or treatments ordered by a physician according to instructions.
Report Facts
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
Annual training hours documented for staff #1: 4.75
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on May 23, 2022, regarding allegations in the areas of medication administration.
Complaint Details
Complaint related to medication administration; allegations were not substantiated based on the investigation.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings are subject to public disclosure and a summary will be posted to the VDSS website.
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 31, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of non-compliance with standards or laws at The Westmont at Short Pump assisted living facility. The investigation included multiple visits on March 31, 2022, April 1, 2022, and April 30, 2022.
Complaint Details
The complaint investigation was substantiated with findings that the facility locked a resident inside her room, restricting freedom of movement, and other violations related to care planning and reporting.
Findings
The investigation found multiple violations including failure to report a major incident within 24 hours, incomplete or untimely Uniform Assessment Instrument (UAI) completion, inadequate reassessments, failure to develop and update individualized service plans (ISP) properly, and failure to provide freedom of movement for residents, including locking a resident inside her room.
Deficiencies (8)
Failed to report an incident to the regional licensing office within 24 hours of any major incident affecting resident safety.
Failed to ensure that a resident's UAI was completed within 90 days prior to admission or updated when condition changed.
Failed to conduct reassessments due to significant changes in resident condition in a timely manner.
Failed to develop a preliminary plan of care within seven days prior to admission addressing resident's basic needs.
Failed to complete a comprehensive individualized service plan within 30 days after admission identifying resident needs and services.
Failed to ensure coordinated plan of care between assisted living facility and licensed hospice organization.
Failed to review and update individualized service plans at least once every 12 months and as needed for significant changes.
Failed to provide freedom of movement for residents; locked a resident inside her room against regulations.
Report Facts
Inspection visit dates: March 31, 2022; April 1, 2022; April 30, 2022
Resident admission date: Resident #1 admitted on 07/12/2021
Incident date not reported: Incident on 12/30/2021 not reported within 24 hours
Work order date for lock installation: Lock placed on resident's door on 02/21/2022 and removed on 02/22/2022
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of non-compliance with standards or laws related to resident care and facility management at The Westmont at Short Pump.
Complaint Details
The complaint investigation was substantiated with findings of non-compliance including missed medication administration, lack of incident reporting, inadequate supervision, and failure to maintain proper resident records.
Findings
The investigation found multiple violations including failure to report major incidents timely, inadequate administration of prescribed medications, lack of proper supervision by the Administrator, failure to provide care as per individualized service plans, incomplete resident records, and failure to ensure medication orders were valid and properly documented.
Deficiencies (8)
Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened resident safety.
Administrator failed to oversee general administration and day-to-day operation, including supervising staff and ensuring resident care.
Facility failed to obtain and review written information on private duty personnel services and notify hiring parties of needed changes.
Facility failed to ensure care and services specified in individualized service plans were provided, including use of protective boots.
Facility failed to ensure resident records were identified and easily located, including documentation of reports to protective services and medication administration records.
Facility failed to implement a written plan ensuring timely filling and refilling of prescription and over-the-counter medications to avoid missed dosages.
Facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued without a valid order from a physician or prescriber.
Facility failed to ensure medication administration records documented any medication errors or omissions.
Report Facts
Inspection dates: 4
Medication missed days: 6
Medication missed days: 4
Medication missed days: 3
Resident admission date: May 17, 2021
Inspection Report
Follow-Up
Deficiencies: 7
Date: Mar 29, 2022
Visit Reason
The inspection was an unannounced non-mandated follow-up visit conducted on multiple days to determine compliance with applicable standards and laws following previous violations.
Findings
The inspection found multiple violations including failure to report major incidents within 24 hours, failure to update fall risk assessments and analyses after falls, incomplete individualized service plans prior to respite care, and inadequate preliminary plans of care that did not address residents' assessed needs.
Deficiencies (7)
Failure to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident.
Failure to ensure that the fall risk rating was reviewed and updated after a fall.
Failure to ensure that the fall risk analysis was reviewed and updated after a fall.
Failure to ensure that the Individualized Service Plan (ISP) for a respite resident was completed prior to participation in respite care.
Failure to ensure that a preliminary plan of care was developed on or within seven days prior to admission to address the basic needs of the resident.
Failure to identify a written description of what services will be provided to address identified needs and who will provide them.
Failure to ensure that Individualized Service Plans (ISP) are reviewed and updated at least once every 12 months and as needed for significant changes in resident condition.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 29, 2022
Visit Reason
The inspection was an unannounced non-mandated follow-up inspection conducted on March 29, 2022 and March 31, 2022 to investigate a complaint related to the facility.
Complaint Details
The complaint investigation found that Resident #1 had a fall on 03/27/2022 requiring emergency medical intervention and hospital admission. The facility did not submit an incident report until 04/04/2022. The evidence supported some of the complaint allegations.
Findings
The investigation supported some, but not all, of the allegations. The facility failed to report a major incident involving a resident's fall and subsequent hospitalization within 24 hours to the regional licensing office, resulting in a violation notice.
Deficiencies (1)
Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident.
Report Facts
Inspection visit dates: Inspection conducted on March 29, 2022 and March 31, 2022
Incident date: Resident #1 fall occurred on 03/27/2022
Incident report submission date: Incident report submitted on 04/04/2022
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 19, 2021
Visit Reason
An unannounced complaint investigation was initiated on 10/19/2021 and concluded on 11/05/2021 to review allegations related to resident care and safety at The Westmont at Short Pump assisted living facility.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to report incidents timely, failed to conduct required mental health screenings, failed to provide care as per individualized plans, and failed to manage a resident's aggressive behaviors appropriately.
Findings
The inspection found multiple violations including failure to report major incidents within 24 hours, failure to conduct mental health screening prior to admission, failure to provide care as specified in individualized service plans, and failure to assume general responsibility for resident health and safety, particularly concerning a resident with aggressive behaviors.
Deficiencies (4)
Failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident.
Failed to ensure that a mental health screening was conducted prior to admission when behaviors indicative of mental illness or behavioral disorders were present.
Failed to ensure that care and services specified in the individualized service plan were provided to a resident.
Failed to assume general responsibility for the health, safety, and well-being of a resident, including inadequate reassessment and care planning for aggressive behaviors.
Report Facts
Incident date: Sep 7, 2021
Resident admission date: Aug 23, 2021
Resident admission date: Aug 9, 2021
Medication dosage: 0.25
Medication dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Inspector | Current inspector conducting the complaint investigation. |
| Director of Nursing | Facility staff made aware of complaint and participated in exit interviews. | |
| Director of Safe and Secure Environment | Facility staff made aware of complaint and participated in exit interviews. | |
| Regional Director of Clinical Services | Participated in exit interview reviewing findings. |
Inspection Report
Renewal
Census: 79
Deficiencies: 7
Date: Oct 6, 2021
Visit Reason
An unannounced renewal inspection was initiated to review compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations related to facility access for inspectors, private duty personnel documentation, fall risk assessments, mental health screenings, discharge documentation, and general responsibility for resident health and safety. Plans of correction were requested for each violation.
Deficiencies (7)
Facility failed to ensure department's representative had reasonable opportunity to inspect all buildings, books, records, and interview relevant persons.
Facility failed to ensure all requirements were met when private duty personnel from licensed home care organizations provide direct care or companion services.
Facility failed to ensure fall risk rating was reviewed and updated after a fall.
Facility failed to ensure mental health screening was conducted prior to admission when indicated by recent behaviors.
Facility failed to ensure mental health screening was conducted when resident displayed concerning behaviors.
Facility failed to provide a complete dated discharge statement containing all required elements at time of discharge.
Facility failed to assume general responsibility for the health, safety, and well-being of a resident, including reassessment and supervision.
Report Facts
Resident census: 79
Resident #3 admission date: Apr 10, 2021
Resident #3 discharge date: Jul 28, 2021
Resident #4 admission date: Jul 27, 2021
Fall assessment date: Aug 2, 2021
Incident date: Jul 22, 2021
Incident follow-up date: Aug 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Inspector | Current Inspector conducting the inspection |
| Angela R. Reaves | Licensing Inspector | Contact person for technical assistance and inspection follow-up |
Inspection Report
Monitoring
Census: 18
Deficiencies: 0
Date: May 13, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted using an alternate remote protocol.
Findings
The inspection determined compliance with applicable standards or laws based on review of resident and staff records and facility documentation submitted by the facility.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Mar 5, 2021
Visit Reason
The inspection was conducted to review the initial application for licensing of the assisted living facility using an alternate remote protocol due to a state of emergency health pandemic.
Findings
The inspection found no violations with applicable standards or law, and no deficiencies were issued. A conditional license is recommended.
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