8341 Lewinsville-Larmax

Based on record review and staff interview, facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, all required information identified in the standard is obtained. Evidence: 1. Resident 3 began having private duty aide on 12/03/2025. 2. During inspection on 01/22/26, Staff 6 confirmed that the facility does not have any of the required documentation for the Staff 2, private duty personnel who provide direct care or companion services to Resident 3.

Based on observation and staff interview, the facility failed to ensure that when the administrator, the designated assistant, or the manager is not awake and on duty on the premises, there shall be a designated direct care staff member in charge on the premises. Evidence: 1. Upon entry on 01/22/2026 at 9am, LI observed that the posted person in charge was Staff 4 identified as the manager on the posting. Staff 1 confirmed that Staff 4 was not present at the facility. 2. Staff 1 confirmed that there was no one in charge of the facility on the premises upon entry. 3. At 9:39am, Staff 5 came on site as the person in charge until Staff 3?s arrival

Based on observation and staff interview, the facility failed to ensure that doors leading to the outside shall not be locked from the inside or secured from the inside in any manner that amounts to a lock. Evidence: 1. Upon entry on 01/22/2026, LI observed Staff 1 type on the keypad to open the main entry door located on the side of the facility to allow LI into the facility. 2. LI observed that both the front door and the main entry door on the side of the facility have a numerical keypad lock that only staff know to leave and enter the facility. 3. This was previously cited during the 01/14/2025 inspection. 4. Staff 1 confirmed that the door always remains locked with the numerical code. 5. Staff 3 acknowledged that the doors still have numerical code locks on both doors after the 01/14/2025 inspection.

Based on observation and interview, the facility failed to ensure that the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: 1. During inspection on 01/22/2026 at 9:25am, LI observed Staff 1 retrieved medication storage room keys from the kitchen cabinet that was accessible to the residents. 2. Staff 1 and Staff 5 acknowledged the keys being in the kitchen cabinet and accessible to the residents.

Based on observation and staff interview, the facility failed to ensure a readily accessible pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medications. Evidence: 1. LI requested facility pharmacy or drug guide. 2. Staff 1 did not know what LI was referring to nor where the reference material was. 3. Staff 4 confirmed that facility does not have a readily accessible pharmacy reference book, drug guide, or medication handbook on site.

Based on observation and staff interview, the facility failed to ensure that doors leading to the outside shall not be locked from the inside or secured from the inside in any manner that amounts to a lock. Evidence: 1. LI observed both front and main entry doors having a numerical keypad lock that only staff member know to enter and to leave. 2. Staff 5 confirmed that both doors have a Mag-Safe Numerical pad lock to get in and out of the facility. 3. During facility tour, LI observed Staff 1 unlocking residents? rooms to enter. 4. Staff 1 confirmed that they lock residents? rooms to prevent entry from other residents. 5. Photo evidence obtained.

Based on observation and staff interview, facility failed to provide freedom of movement for the residents to common areas and to their personal spaces. The facility shall not lock residents out of or inside their rooms. 1. During facility tour, LI observed Staff 1 unlocking residents? rooms to enter. 2. Staff 1 confirmed that they lock residents? rooms to prevent entry ?from other residents."

Based on record review and staff interview, the facility failed to ensure that a mental health screening shall be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative substance abuse and/or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident 2 (DOA:10/01/2024) history and physical (Completed: 9/23/2024) & ISP

Based on record review and staff interview, the facility failed to ensure that direct care staff are trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. Evidence: 1. Resident 2 (DOA:10/01/2024) history and physical (Completed: 9/23/2024) indicated aggressive behaviors with associated medication management. 2. Staff 4 confirmed that the resident was admitted to the facility due to their behavior. 3. Staff 1 confirmed Resident 2 has behaviors frequently. 4. The facility does not have a training that suffices the required training methods.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.