VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Larmax Homes - 8337 Lewinsville
8337 Lewinsville Road
Mc lean, VA 22102
(571) 730-4029

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: June 24, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of Inspection: Monitoring Inspection Date of Inspection: May 2 2024 -9am 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: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and participating in other scheduled activities. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on record review and staff interview, facility failed to ensure that fall risk ratings are completed annually. Evidence: 1. Resident 1 last fall risk rating was dated 3/02/2023. 2. Staff 3 stated that she did not know an annual fall risk was required in Virginia and will get them updated.
Plan of Correction:	Correction: Larmax is developing a new and more comprehensive risk assessment for our residents, which will include falls. Prevention: These fall assessments will be initiated before the resident enters the home and will be reviewed annually Responsible Party: Director of Nursing
Standard #:	22VAC40-73-350-C
Description:	Based on record review and staff interview, facility failed to ensure that each resident or his legal representative is fully informed, prior to or at the time of admission and annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered pursuant to Chapter 9 (? 9.1-900 et. seq.) of Title 9.1 of the Code of Virginia, including how to obtain such information with written acknowledgement maintained in the resident record. Evidence: 1. Resident 1 and Resident 2?s record did not have any acknowledgement or documentation in record. 2. Staff 3 confirmed they have not been completing this notification to residents or family.
Plan of Correction:	Correction: As part of the admission process, Larmax obtains criminal background checks on the potential resident and places the document in their file. Files were audited to ensure this document is present. Prevention: Larmax will add to the admission process a form that families sign concerning their right to do their own due diligence and how to do it. We would welcome any forms/language that the state deems acceptable for this process. This will be added to the forms signed upon admission. Responsible Party: Administrator
Standard #:	22VAC40-73-410-A
Description:	Based on record review and staff interview, facility failed to provide and document orientation for new residents. Evidence: 1. Resident 1 and Resident 2 charts were reviewed with no documentation in record acknowledging orientation. 2. Staff 4 confirmed that they review with resident and family, but they do not have documentation for it.
Plan of Correction:	Correction: Families' orientation is currently completed via teams prior to a resident?s admission. This process now includes an updated checklist to document the current practice. Prevention: Larmax has implemented a resident/family orientation checklist that will be signed and placed in the resident's chart upon admission. Responsible Party: Administrator
Standard #:	22VAC40-73-550-F
Description:	Based on observation and staff interview, facility failed to ensure resident rights is posted with the name and telephone number of the appropriate regional licensing supervisor of the department, the Adult Protective Services' toll-free telephone number, the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any substate (i.e., local) ombudsman program serving the area, and the toll-free telephone number of the Disability Law Center of Virginia. Evidence: 1. Resident Rights was posted publicly but facility used their own formatting and edits made to the document did not include any of the required contact information for required officials. 2. LI showed Staff 3 a copy of VDSS Resident Rights for reference from online forms and staff 3 confirmed she didn?t know to list or post the contacts.
Plan of Correction:	Prevention: Upon admission, residents and their families will be provided with a list of resident rights to include the above-stated services. This process will be audited quarterly by the Administrator. Responsible Party: Administrator
Standard #:	22VAC40-73-950-A
Description:	Based on record review and staff interview, the facility failed to develop written emergency procedures to address: Locating and shutting off utilities when necessary and building and site maps necessary to shut off utilities. Evidence: 1. LI reviewed emergency preparedness plan and there was no mention of shutting off utilities nor was there a map included or attached to indicate where to shut off utilities. 2. LI showed standard and missing items on plan. Staff 3 confirmed that the listed provisions are missing on the plan.
Plan of Correction:	Correction: Larmax Homes has a disaster and emergency preparedness plan that staff can use to locate and shut off utilities. Prevention: Staff will be re-educated on the on-site maps, the location of shut-off points, and how to operate those if needed. Responsible Party: Administrator
Standard #:	22VAC40-73-950-F
Description:	22VAC40-73-950-F Based on record review and interview, facility failed to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Such revisions shall be communicated to staff, residents, and volunteers. Evidence: 1. LI requested documentation of review for staff, residents, and volunteers. 2. Staff 3 confirmed that the facility does not have any documentation of any emergency preparedness plan review for staff or residents.
Plan of Correction:	Correction: A meeting was held with the administrator and Larmax?s interdisciplinary team to review and accept the company's 2024 plans, which included the Emergency Preparedness Plan (EPP). Prevention: During the Senior Leadership meeting, all plans will be explained, reviewed, and agreed upon. They will be acknowledged by signatures from the administrator and RN. Responsible Party: Administrator
Standard #:	22VAC40-73-960-C
Description:	Based on observation and staff interview, facility failed to post the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center by each telephone shown on the fire and emergency evacuation plan. Evidence: 1. LI reviewed phones posted on evacuation map. The phones only had the facility phone number posted. None of the emergency contact numbers were posted by the phone. 2. Staff 3 confirmed that she knew that they are to be posted and will make sure that is completed.
Plan of Correction:	Correction: All phones have current emergency phone numbers located by them. The evacuation maps will be updated to show the location of these phones Prevention: Operation leadership will conduct random mock surveys to ensure these numbers are ?up-to-date? and accurate. Staff will continue to be educated on the importance of these numbers, and audits will be completed to ensure compliance. Responsible Party: Vice President of Operations
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interview, the facility failed to ensure a complete first aid kit is on hand. Evidence: 1. First aid kit on hand did not include: Tape, disposable blankets, roller gauze, plastic bags, scissors, flashlight, batteries, thermometer. 2. Staff 3 stated that all the homes have the same first aid kit with missing items and will have the other items added.
Plan of Correction:	Correction: During the survey, we purchased and implemented new first aid kits. The kits satisfy regulation 22VAC40-73-980-A. Prevention: Mock surveys have been initiated. House staff will check First aid kits monthly to ensure all items are restocked During the survey, First Aid kits will be reviewed and audited. Responsible Party: Vice President of Operations
Standard #:	22VAC40-73-980-C
Description:	Based on record review and staff interview, facility failed to ensure month first aid kits are checked at least monthly to ensure all items are present. Evidence: 1. LI requested evidence of monthly check of first aid kit. 2. Staff 3 confirmed that facility has not been checking first aid kit monthly.
Plan of Correction:	Correction: During the survey, new first aid kits we purchased and implemented. The first aid kits satisfies regulation 22VAC40-73-980-A. Prevention: Mock surveys have been initiated. House staff will check First aid kits monthly to ensure all items are restocked During the survey, First Aid kits will be reviewed and audited. Responsible Party: Vice President of Operations