VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Chantilly
2980 Centreville Road
Herndon, VA 20171
(703) 994-4561

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Dec. 20, 2023

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 GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Technical Assistance:

Documentation was discussed with the provider.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/28/23 (9:00 AM - 5:15 PM) Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: Eight Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: Meals, medication administration, activities 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-200-C
Description:	Based on record review, the facility failed to ensure that each direct care staff member meets one of the required qualifications. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment. Evidence: One out of four staff records (Staff #2) did not contain one of the required direct care staff qualifications. Staff #2 has a hire date of 6/8/22, but her record did not contain documentation that she met one of the direct care staff qualifications listed in 22VAC40-73-200-C.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure that training information is included in the staff record. Evidence: Staff training was requested during the inspection. Four out of four staff records (Staff #1, #2, #3, and #4) did not contain information about their completed annual training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member annually submits the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Four out of four staff records (Staff #'s 1,2,3, and 4) did not contain the results of a tuberculosis risk assessment that was completed within the past year.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Evidence: Two out of four staff records (Staff #'s 2 and 3) did not contain current certification in first aid.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure that the individualized service plan (ISP) is reviewed and updated. Evidence: Resident #3's Uniform Assessment Instrument (UAI), dated 9/19/23, states that he needs supervision for dressing. Resident #3's ISP, dated 11/8/23, includes information that states Resident #3 does "not require assistance with dressing," and another portion of the ISP indicates that he needs physical assistance in order to get dressed. Resident #4's record contained a DNR order, dated 3/14/23. Resident #4?s ISP does not include the resident?s DNR order, and lists the resident as full code. Resident #5's UAI, dated 8/4/23, states that she needs mechanical and physical assistance for bathing, dressing, toileting and transferring. The ISP in Resident #5's record, dated 2/4/23, states that she can bathe without physical assistance, but that she may require reminding or standby assistance. The ISP also states that Resident #5 is able to get dressed independently and that she only requires standby assistance for toileting. The ISP states that Resident #5 needs verbal prompts/cues for transferring, and that hands on assistance is not needed. Resident #6's record included a hospice order, dated 6/26/23. Resident #6's ISP, dated 8/14/23, does not include information about the resident?s hospice services.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure that PRN medications are available and properly stored at the facility. Evidence: Resident #2's PRN medications were reviewed during the inspection. Resident #2's Nitroglycerin (ordered 12/21/21) and Imodium (ordered 4/10/23) were not present at the time of the medication cart inspection. Facility staff confirmed that the listed PRN medications were not present at the time of the medication cart inspection. Resident #9's PRN medications were reviewed during the inspection. Resident #9's Miralax (ordered 12/14/22), Robaxin (ordered 11/17/22), Senna (ordered 12/14/22) and Tramadol (ordered 11/17/22) were not present at the time of the medication cart inspection. Facility staff confirmed that the listed PRN medications were not present at the time of the medication cart inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based on observation and record review, the facility failed to ensure that cleaning supplies and other hazardous materials are kept in a locked area. Evidence: Denture cleaning tablets, Neosporin, cortisone cream, and preparation H were observed in the bathroom of Resident #2 of the special care unit. Resident #2's record contained an assessment of serious cognitive impairment, that states that she has a serious cognitive impairment with an inability to recognize danger, or protect her own safety and welfare.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report within 30 days of each employee's hire date. Evidence: Background checks for new employees, hired since the last inspection, were reviewed during the inspection. No background checks were provided during the inspection for the following staff members: Staff #5 (hired 9/3/23), Staff #6 (hired 10/11/23), Staff #7 (hired 9/1/23), Staff #8 (10/18/23), Staff #9 (hired 6/19/23), Staff # 10 (hired 10/16/23) and Staff #11 (hired 10/16/23).
Plan of Correction:	Not available online. Contact Inspector for more information.