Westwood Center Assisted Living Facility

Based on review of staff records, the facility failed to have staff to attend six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment. EVIDENCE: 1. Staff #2 was hired on 07/29/2025. 2. This facility provides care and services to residents with cognitive impairments. 3. As of 02/10/2026, staff #2 has three of the required six hours of training which must be completed withing four months of the start date of employment.

Based on review of resident records, the facility failed to have written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative retained in the resident's record. EVIDENCE: 1. Residents #1 and #2 were admitted on 12/01/2025. Neither residents? record included documentation that the disclosure form had been provided to them or their responsible party.

Based on review of staff records, the facility failed to provide written documentation of duties and responsibilities prior to a direct care person being placed in charge. EVIDENCE: 1. Staff #2 was hired on 07/29/2025. 2. Documentation of duties and responsibilities for staff #2 was not located in the personnel file prior to the employee being assigned "in charge" status.

Based on review of staff records, the facility failed to include the name and telephone number of a person to contact in case of an emergency. EVIDENCE: 1. Staff #1 was hired on 11/18/2025. On the date of the inspection, 02/10/2026, there was no emergency contact listed in staff #1?s file. 2. Staff #2 was hired on 07/29/2025. On the date of the inspection, 02/10/2026, there was no emergency contact listed in staff #2?s file.

Based on staff interviews, the facility failed to maintain a written staffing plan that specifies the number and type of direct care staff required to meet the day-to-day routine direct care needs of residents in care. EVIDENCE: 1. According to an interview with staff #2 and staff #3 the assisted living facility shares staff with the skilled nursing facility and does not have 24/7 dedicated staff for the assisted living side of the building.

Based on interviews with staff, the facility failed to have a method of written communication as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents. EVIDCENCE: 1. According to an interview with staff #2 and #3 the facility does not keep a written communication log between shifts.

Based on review of resident records and staff interviews, the facility failed to provide written assurance to the resident or responsible party and to maintain a copy in the resident?s record prior to admission to an assisted living facility. EVIDENCE: 1. According to an interview with staff #3 there was no written assurance available for resident #1 or #2 in their file on the date of the inspection.

Based on review of resident records, the facility failed to ensure a person shall have a physical exam and a tuberculosis assessment 30 days preceding admission to an assisted living facility. EVIDENCE: 1. Resident #1 was admitted to the facility on 12/01/2025. The most recent physical examination and tuberculosis screening were completed on 02/13/2025. 2. Resident #2 was admitted to the facility on 12/01/2025. The most recent physical examination and tuberculosis screening were completed on 09/28/2025.

Based on review of resident records, the facility failed to complete a fall risk rating for residents who meet the criteria for assisted living by the time the comprehensive Individualized Service Plan is completed. EVIDENCE: 1. Residents #1 and #2 were admitted to the assisted living facility on 12/01/2025 as assisted residents. 2. On the date of the inspection, 02/10/2026 a fall risk had not been completed on residents #1 or #2.

Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates a stay greater than three days and the date the information was obtained. EVIDENCE: 1. Resident #1 and #2 were admitted to the facility on 12/01/2025. As of the date of the inspection, 02/10/2026, a sex offender check had not been done prior to the admission to the assisted living facility.

Based on resident record review, the facility failed to have a dated and signed agreement between the resident and the facility. EVIDENCE: 1. Resident #2 was admitted to the facility on 12/01/2025. There was a resident agreement in the file but it was not signed by the resident or the resident?s responsible party. The signature line said ?Verbal consent?. 2. Verbal consent was granted by resident #2 who is capable of making her own decisions.

Based upon resident record review, the facility failed to provide an orientation for new residents upon their admission to the assisted living facility. Acknowledgement of having received the orientation shall be signed and dated by the resident or his responsible party and shall be kept in the resident?s record. EVIDENCE: 1. Resident #1 was admitted to the assisted living facility on 12/01/2025. Resident orientation documentation was not available in resident #1?s file. 2. Resident #2 was admitted to the assisted living facility on 12/01/2025. Resident orientation documentation was not available in resident #2?s file.

Based on resident record review, the facility failed to complete the private pay Uniform Assessment Instrument ( UAI

Based on resident record review, the comprehensive Individualized Service Plan ( ISP

Based on resident record review, the facility failed to have the Individualized Service Plan ( ISP

Based on observations made during the tour of the building, the facility failed to ensure posted menus were dated. EVIDENCE: 1. The menu hanging in the facility did not have the dates labeled on the menu.

Based on review of physician?s orders, the facility failed to include all the necessary components required by assisted living standards on the order. EVIDENCE: 1. Resident #1 has an order for Voltaren. 2. The frequency that Voltaren is to be administered is not included on the physician?s order.

Based on resident record review, the facility failed to have physician?s orders filed chronologically in the resident?s record. EVIDENCE: 1. On the date of the inspection, 02/10/2026, staff #2 was observed administering Methenamine to resident #2 during the morning medication pass. 1. The medication was not listed on the February 2025 MAR

Based on the review of physician?s orders and the Medication Administration Record ( MAR

Based on the review of the February 2026 Medication Administration Record ( MAR

Based on observations made during the morning medication pass, review of Medication Administration Records ( MAR

Based on observations made during the tour of the building, the facility failed to keep all fixtures and appliances in good repair. EVIDENCE: 1. In the dayroom only two of the four overhead ceiling lights were operable. 2. The overhead ceiling light at the end of the hall near the exit door was found to have dead insects in the covering.

Based on observations made during the audit of the first aid kit, the facility failed to maintain a complete and stocked first aid kit. EVIDENCE: 1. The first aid kit did not contain adhesive tape, antiseptic wipe or ointment, nor hand cleaner.

Based on review of staff records, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff #4 was hired on 09/30/2025. The criminal record history was completed on 01/26/2026 for staff #4. 2. Staff #5 was hired on 08/01/2025. The criminal record history was completed on 01/26/2026 for staff #5. 3. Staff #2 was hired on 07/29/2025. The criminal record history was completed on 01/26/2026 for staff #2. 4. Staff #3 was hired on 07/28/2025. The criminal record history was completed on 10/14/2025.

Based on staff interviews, the facility failed to notify the department?s regional licensing office in writing within 14 days of a change in a facility?s administrator, including the resignation of an administrator, appointment of an acting administrator, and appointment of a new administrator. EVIDENCE: 1. On the date of the inspection (08/07/2025) the LI asked the front desk staff to speak with the administrator of the assisted living facility. 2. Staff #1 introduced herself as the administrator of the assisted living facility. 3. The LI informed staff #1 that the regional licensing office had received the resignation of the previous administrator by email on 07/07/2025. 4. The LI let staff #1 know there has been no further communication as of the date of this inspection (08/07/2025) from the facility in regards to a replacement administrator.

Based on review of resident records, the facility failed to prepare and provide a disclosure statement to the prospective resident and his legal representative. EVIDENCE: 1. Resident #1?s file did not contain a disclosure statement.

Based on review of staff records, the facility failed to make sure all direct care staff attend at least 18 hours of annual training. EVIDENCE: 1. Staff #1 was hired on 2/13/2020 and staff #2 was hired on 1/23/2020. The records provided to the (LI) Licensing Inspector by staff #6 did not include the number of hours, a description of the training nor did it total 18 hours annually.

Based on review of staff records, the facility failed to make sure all direct care staff attend at least two hours of annual infection control training and four hours of mental impairment training. EVIDENCE: 1. Staff #1 was hired on 2/13/2020 and staff #2 was hired on 1/23/2020. The records provided to the (LI) Licensing Inspector by staff #6 did not include the number of hours, a description of the training nor did it document two hours of infection control training annually or four hours of working with adults with mental impairments.

Based on resident record review and staff interview, the facility failed to have a documented interview between the administrator or designee responsible for admission and the individual prior to admission to the facility to ensure the facility can meet the needs of the individual. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/16/2024. 2. According to an interview with staff #3 and review of resident #1?s file, there was no documented written assurance or interview prior to or at the time of admission to the facility.

Based on review of resident records, the facility failed to include a description of the person?s reactions to any known allergies listed on the physical preceding admission to an (ALF) Assisted Living Facility. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/16/2024. 2. A physical for Resident #1 was completed on 10/16/2024 and listed penicillin as an allergy, but it did not list a description of the person?s reactions.

Based on resident records, the facility failed to complete a fall risk rating for residents who meet the criteria for assisted living care by the time the comprehensive ( ISP

Based on resident records, the facility failed to complete a fall risk rating at least annually. EVIDENCE: 1. Resident #2 was admitted to the facility on 02/17/2020. 2. Fall risks were completed on 12/15/2020, 02/16/2021, and 11/20/2022. There was fall risk found in the file but, it was not dated. 3. There was not a fall risk available in the file for 2023 or 2024 for Resident #2.

Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. EVIDENCE: 1. Resident #1?s file did not contain documentation that this information was ascertained.

Based on resident record review, the facility failed to have a signed and dated written agreement between the resident and the facility. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/16/2024. 2. Resident #1?s file did not contain a signed and dated agreement between the resident and the facility.

Based on resident record review, the facility failed to have a signed and dated acknowledgement that one resident had received an orientation to the facility. EVIDENCE: 1. Resident #1 was admitted to the facility on 10/16/2024. 2. When reviewing the file for resident #1, there was no signed and dated acknowledgement that resident #1 had received an orientation to the facility.

Based on resident record review, the facility failed to compete the private pay UAI

Based on review of resident records, the facility failed to have all needs and required components on the comprehensive ( ISP

Based on review of resident records, the facility failed to have the ISP

Based on review of physician?s orders, the facility failed to include the route and the diagnosis on one residents physician?s orders. EVIDENCE: 1. Resident #3 has a physician?s order signed on 02/06/2025 for Namenda 5mg, BID. 2. There is no route the medication should be taken and no diagnosis for what the medication will be used for on the physician?s order signed on 02/06/2025.

Based on observations made during the tour of the facility, the facility failed to store medications administered by the facility in a locked storage area. EVIDENCE: 1. When the LI entered the facility for the inspection on 02/18/2025 at 11:30 am, the ALF medication cart was found to be unlocked and unattended. Medication was found to be stored inside the cart when LI opened the drawers. 2. The North cart (belonging to the Skilled Nursing Facility) was found with two boxes of Iprat-Albuterol 0.5-3mg on the top of the medication cart unlocked and unattended. This medication cart was sitting in front of the nurse?s station, which is part of the licensed Assisted Living Facility.

Based on review of physician?s orders and MAR

Based on review of the ( MAR

Based on an audit of the first aid kit, the facility failed to maintain items with expiration dates that have not passed. EVIDENCE: 1. The hand cleaner in the first aid kit expired in 06/2024.

Based on staff interviews and review of staff records, the facility failed to ensure continuing education required by the Virginia Board of Nursing for medication aides was included in one of the three staff records. EVIDENCE: 1. Staff #1 has been employed at the facility since 02/15/2006 and has current certification as a medication aide with the Virginia Board of Nursing. 2. LI could not locate documentation that staff #1 has completed the required four-hour refresher course for medication aides on the date of the inspection (02/29/2024). 3. During the exit interview the LI asked staff #4 and staff #5 if the facility had documentation of the four-hour refresher course for staff #1. 4. The LI was not provided with any verification of completion/documentation of the four-hour medication refresher training for staff #1.

Based on review of staff records, the facility failed to maintain results of an annual TB risk assessment. EVIDENCE: 1. Staff #1 was hired on 02/15/2006. An annual TB risk assessment was not able to be located in her file for the past year. 2. Staff #3 was hired on 02/20/2020. An annual TB risk assessment was not able to be located in her file for the past year.

Based on record review and interviews, three of the three staff records did not contain documentation of current certification of first aid. EVIDENCE: 1. LI was not able to locate current certification in first aid for staff #1, #2, or #3. 2. During the exit interview, the LI asked everyone present if there was anywhere else the first aid certification could be located for staff #1, #2, and #3. There was no further documentation provided. 3. Staff #1 began employment on 02/15/2006; staff #2 began employment on 09/20/2023; and staff #3 began employment on 02/20/2020. All three staff have been employed at this facility for greater than 60 days.

Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a register sex offender. EVIDENCE: 1. Resident #1 was admitted to the facility on 08/03/02. A sex offender check has not been completed on Resident #1 as of the date of the inspection (02/29/2024).

Based on interviews with staff, the facility failed to have the licensee, administrator, or his designee who has successfully completed the department approved ISP

Based on resident record review and interview with staff, the facility failed to have the ISP

Based on interviews with staff, the facility failed to complete the health care oversight for an unknown amount of time. EVIDENCE: 1.According to an interview with staff #4 and staff #5 it is unclear of the date of the last health care oversight completed at the assisted living facility.

Based on resident record review, the facility failed to maintain evidence of the annual resident right review in the resident?s record for two residents. EVIDENCE: 1. There was no written acknowledgement in resident #2?s file nor resident #3?s file to show the resident or his legal representative or responsible individual had been informed of the resident rights on an annual basis.

Based on observations made during the tour of the building the facility failed to store cleaning supplies in a locked area. EVIDENCE: 1. The bathroom inside of the day room was found to have a 12 oz hand sanitizer and a 150 count of germicidal bleach wipes in the first and second drawer of the vanity. Both have statements to ?keep out of the reach of children? on them. 2. In the second drawer of the vanity non-acid bowl and bathroom disinfectant cleaner was located. The statement, ?hazard to humans and domestic animals? was printed on the back of the container. 3. According to an interview with staff #1, this facility does have cognitively impaired individuals that have access to this bathroom inside the day room.