VIRGINIA DEPARTMENT OF SOCIAL SERVICES

LARMAX HOMES - 8341 Lewinsville
8341 Lewinsville Road
Mc lean, VA 22102
(571) 353-1010

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: June 25, 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: June 25 2024 - 8am - 2:30pm 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: 2 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 #:	22VAC40-73-100-A
Description:	Based on record review and staff interview, facility failed to ensure and maintain documentation of an annual review of infection prevention policies and procedures. Evidence: 1. LI reviewed infection control policy and further requested annual review documentation of infection control policy. 2. Staff 3 reached out to other administration staff and confirmed they do not have any annual review documentation.
Plan of Correction:	Correction: We?ve been working very closely for several years with representatives from the VDSS regarding our infection control policies and procedures, including an onsite review on February 20, 2024. The next review is scheduled for August, 2024. These reviews are ongoing and designed to continually improve our policies; a letter from VDSS is available showing the results of our collective review. We will ensure that staff knows where to find documentation of such reviews. Should such reviews stop, we will ensure that we prepare a form documenting an annual review. Prevention: We will add this item to our internal document audit checklist and teach house staff where to locate proof of review in the event of an inspection. Responsible Party: Director of Nursing
Standard #:	22VAC40-73-50-A
Description:	Based on record and staff interview, facility failed to ensure all required information are included of the disclosure statement. Evidence: 1. LI reviewed disclosure statement (revised January 2020) and noted that it was missing whether or not the facility maintains liability insurance, whether or not the facility has an on-site emergency electrical power source and notation that additional information about the facility that is included in the resident agreement is available. 2. Staff 3 and staff 4 were provided copies of VDSS disclosure statement and confirmed missing items. Staff 3 confirmed she will use VDSS form.
Plan of Correction:	Correction: The Uniform Disclosure statement, which is the VDSS form, was updated by Larmax on July, 2023 and includes the listed items. Upon admission, the most recent version of the disclosure statement is signed by the resident?s representative and included in the resident?s file. Prevention: Larmax?s marketing assistant will periodically review these files to ensure that all information remains current and that compliance is being met. Responsible Party: Administrator
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 #:	22VAC40-73-550-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:	Correction: Resident rights have been updated to include the 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 posted 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 #:	22VAC40-73-610-B
Description:	Based on observation and staff interview, facility failed to post a weekly menu for meals and snacks for the current week that is dated. Evidence: 1. LI toured kitchen and LI heard staff asking residents what they want to eat for breakfast. 2. LI requested the weekly menu. Staff 1 informed that they ask the residents what they want to eat instead of planning a weekly menu for them. 3. Staff 1 confirmed that she did not know there was supposed to be a planned-out menu for the week and if changes are made to update it.
Plan of Correction:	Correction: In our mission to provide true person-centered care, each of the 8 residents (or their representatives) in our houses are asked when they are admitted what are their preferences for breakfast and then those items are made available, on an individualized basis, every morning. Prevention: Larmax will be developing breakfast meal times based on the correction Responsible Party: Vice President of Food Service
Standard #:	22VAC40-73-650-C
Description:	22VAC40-73-650-C Based on record review and staff interview, facility failed to ensure Physician's or other prescriber's oral orders are reviewed and signed by a physician or other prescriber within 14 days. Evidence: 1. Resident 1 record contained an oral order taken by RN for portable x-ray on 03/05/2024. The order was signed by physician on 03/14/2024. 2. Resident 2 record contained an oral order taken by RN on 8/24/2023 for probiotic and C-diff collection. Order was signed by physician on 11/11/2023. 3. Resident 2 record contained an oral order taken by RN for UTI culture on 7/12/2023. Physician signed on 11/11/2023. 4. Staff 3 and staff 4 confirmed that the orders weren?t signed due to a lapse in physician coming to the facility, but they now have a permanent physician.
Plan of Correction:	Correction: The nursing team has completed audits to ensure that all orders have been signed and are in compliance with 22VZC40-73-650-C Prevention: The nursing teams will check and audit orders to ensure all prescribers have been notified that orders need to be signed within 14 days. Larmax will also document all communications with the prescribers. The administrator and the nursing team will audit this process for compliance. Responsible Party: Director of Nursing
Standard #:	22VAC40-73-680-C
Description:	Based on observation and interview, facility failed to ensure medications are administered not earlier than one hour before and not later than an hour after for a medication ordered for a specific time. Evidence: 1. LI observed morning medication pass of resident 1. Resident 1 medication pass time is for 8am on computer. Medication blister packs are also listed for 8am (Gabapentin, Eliquis and Risoquad) were administered at 9:21am. 2. LI asked Staff 1 before medications were given to Resident 1 why medications are being administered at 9:21am out of the 1-hour window. Staff 1 stated that they always give them around this time because that is when he is up and ready for breakfast. Staff 1 confirmed that the medications are never given earlier than 8am within the 1-hour window. 3. Staff 3 and Staff 4 stated that they did not know the medications were being given outside the window of time for Resident 1.
Plan of Correction:	Correction: Working with physicians as needed, Director of Nursing will adjust, where possible, timing of medications to reflect resident preferences and/or diurnal rhythms. Prevention: Chart audits will include a section looking at whether or not medications are administered pursuant to the appropriate schedule. Responsible Party: Director of Nursing
Standard #:	22VAC40-73-940-A
Description:	22VAC40-73-940-A Based on record review and staff interview, the facility failed to ensure compliance with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. LI requested annual fire inspection. Staff 3 confirmed that the inspection has not been completed and fire official is to come out the next day (6/25/2024).
Plan of Correction:	Not available online. Contact Inspector for more information.
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:	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