The violation emerged during a complaint investigation about the admission of residents listed on the Virginia State Police Sex Offender Registry. Federal inspectors found that Resident 112, who was on the registry, had no care plan addressing sexual or inappropriate behavior monitoring.
The resident was admitted with serious cardiac conditions including congestive heart failure and a left ventricular assist device. Mental status testing showed the person scored 15 out of 15 on cognitive assessments, indicating no cognitive impairment. The resident required supervision for bathing, transfers, dressing and toileting but could eat independently.
His comprehensive care plan from October 2024 focused entirely on medical compliance issues. It noted the resident "has behaviors refuses cardiac clinic appointments" and "refuses daily weights," with interventions aimed at encouraging routine weight monitoring and arranging facility visits from cardiac clinic staff.
No behavioral monitoring related to sexual conduct appeared anywhere in the plan.
When inspectors asked Director of Nursing ASM 2 whether monitoring sexual or inappropriate behaviors should be included in care plans for sex offender registry residents, she was unequivocal.
"It should be on the care plan," she said. "I would expect it to be there."
It wasn't there.
The facility's own policies require exactly what was missing. The care planning policy states that licensed nurses, working with interdisciplinary teams, must develop individualized care plans "to provide effective, person-centered care" and maintain residents' "highest practical physical, mental and psychosocial well-being."
The behavioral assessment policy is even more specific. It requires that "behaviors will be assessed and monitored" with "factors influencing behaviors, as well as management interventions" evaluated and incorporated into care planning.
Federal inspectors conducted their review as part of a broader complaint investigation into the facility's admission practices for sex offender registry residents. The December 17 inspection involved interviews with multiple administrators, including the facility administrator and both the director of nursing and assistant directors of nursing.
All four administrators were made aware of the concerns during a 2:00 PM meeting that day.
The violation represents a fundamental failure in care planning requirements. Federal regulations mandate that nursing homes develop complete care plans addressing all resident needs, with measurable actions and specific timetables. For a cognitively intact resident on the sex offender registry, behavioral monitoring becomes a critical safety component.
The resident's cognitive clarity makes the oversight more significant. Unlike residents with dementia or other cognitive impairments who might not understand behavioral expectations, this person scored perfectly on mental status testing. The facility knew exactly who they were housing and what risks might be involved.
Westport's care plan addressed the resident's tendency to refuse medical appointments and weight monitoring, showing staff recognized and planned for other behavioral patterns. But the same systematic approach never extended to sexual behavior monitoring, despite the resident's registry status.
The facility provided no additional information to inspectors before they completed their review.
The violation affects how facilities across Virginia handle admissions of sex offender registry residents. While nursing homes cannot automatically exclude people based on criminal history, they must develop appropriate monitoring and safety measures once admitted.
Resident 112's case illustrates the gap between policy and practice. The facility had written procedures requiring behavioral assessment and monitoring. Administrative staff understood the requirements. But the actual care plan ignored the resident's most significant behavioral risk factor.
The inspection found minimal harm to residents, but the potential for actual harm was clear. Without proper behavioral monitoring protocols, facilities cannot prevent inappropriate conduct or protect other residents from potential victimization.
Federal regulations exist specifically to prevent such oversights. Care plans must be comprehensive, addressing all aspects of resident needs and safety. When facilities admit high-risk individuals, those plans become even more critical.
The resident continues living at Westport while the facility works to correct the deficiency. But the case raises questions about how many other registry residents might be housed in Virginia nursing homes without appropriate behavioral monitoring safeguards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westport Rehabilitation and Nursing Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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