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: July 31, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 63.2- (1) GENERAL PROVISIONS

Technical Assistance:

N/A

Comments:

Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 07/12/2024 regarding allegations in the area(s) of: resident care and related provisions. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/31/2024 9:12 AM to 12:15 PM 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: 45 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Special Care Unit. Additional Comments/Discussion: N/A. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident but identified during the course of the investigation can also be found on the violation notice. 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 the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident is reported to the regional licensing office within 24 hours. Evidence: 1. Resident 1?s progress notes from 07/06/2024 at 10:13 PM that state a. ?Around 7:40 PM CNA told me that [CNA] can't found [Resident 1] in [Resident 1?s] room .We checked all the room and we started looking in and out of building we finally found [Resident 1] outside the building .[Resident 1] is fine and we take [Resident 1] in [Resident 1?s] room. now [Resident 1] is in [Resident 1?s] room. Informed Director of Nursing, Lead med tech. Informed to family member [husband?s name] about the incident. [Resident 1?s] husband [husband?s name] told that he is comming tommorow to see [Resident 1].? 2. Staff 1 stated that it was not reported because Resident 1 was found within the building. 3. Staff 2 confirmed that Resident 1 was found outside of the building in the parking lot.
Plan of Correction:	Executive Director will timely review and timely report all incidents within the time frame outlined in standard 22VAC40-73-70 requiring notification within 24 hours of any major incident will be implemented immediately. Staff training on ?mandated reporter? will be conducted by November 26, 2024.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) is signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative Evidence: 1. Resident 2?s ISP, completed 02/28/2024, was signed by two community staff. The ISP was not by the resident and/or the resident?s legal representative. 2. Upon request to Staff 1 and Staff 2, a copy signed by the resident or legal representative of Resident 1 and Resident 2?s ISPs were not provided.
Plan of Correction:	Executive Director will contact Resident #2 or legal representative to sign resident?s ISP. An 100% audit of all resident records will be conducted to ensure a signed and dated Individualized Service Plan is on file. A random monthly review of resident records will be conducted by the Health Care Director to ensure compliance in accordance with this standard. The plan of correction will be fully implemented, and noncompliance promptly corrected by November 26, 2024.
Standard #:	22VAC40-73-460-D
Description:	Based on facility document review, resident record review, and staff interview, the facility failed to ensure that supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises was provided. Evidence: 1. Resident 1, admitted 07/03/2024, resides in the safe secure unit. 2. On 07/11/2024, Resident 1?s Progress notes contain a behavior note written by Staff 5 at 10:27 PM that state ?At 9;05 pm CNA called RMA to inform [RMA] hat [CNA] could not find [Resident 1] in [Resident 1?s]room or the common area, around the same time police called in to checked if we have a resident by [Resident 1?s Name] RMA said yes and the police said he is coming in the community. He came in and told RMA and the cna that someone saw the resident at the exon gas station close to the community and called 911, 911 came and ask [Resident 1] how [Resident 1] got there [Resident 1] said that [Resident 1] drove there, The police said [Resident 1] seemed ok but they had to call an ambulance to take [Resident 1] to the reston hospital for further check up. ED, DON, and the resident?s husband were notify. resident?s husband said he was going to the hospital to bring [Resident 1] back after [Resident 1?s check up.? 3. Staff 1 confirmed that Resident 1 followed a private duty aide out of the door. 4. Rounding logs from July 11, 2024 signed by Staff 5 document that Resident 1 was in bed in their room at 7:00 PM. 5. In a handwritten statement from Staff 6, it is documented that ? [Resident 1] was tired and went to bed by 6:40 or 6:45 pm. Medtech went to check on [Resident 1] before going to the other floor. [Resident 1] was in bed. Another resident was wet and we went to change her. When we came back to the sitting area, and the other CNA went to check on her, she was not in her room or any of the other rooms.? 6. In a handwritten statement from Staff 4, it is documented that ?What has happen that day [Resident 1] was in bed sleeping. So we went to put this lady [Room Number] in bed. So I make a check on [Resident 1] but [Resident 1] was no were to be found.? 7. Video footage of the incident was reviewed on the date of inspection that showed Resident 1 dressed in a blue sweater, white pants, shoes, and a purse exiting the facility through the lobby and turning right on the sidewalk at approximately 8:08 PM. 8. On 07/11/2024, the National Weather Service indicates a high temperature of 91 for July 11, 2024, and a low temperature of 66 on July 11, 2024. 9. Staff 1 states they were able to review the outdoor footage of the parking lot until the resident was off property. Resident 1 remained on the sidewalk headed toward to the Exxon Gas Station. The Exxon gas station is located approximately 0.2 miles from the facility on a flat incline at the intersection of McLearan Road and Centreville Road. 10. The Virginia Department of Transportation indicates that McLearan Road has an average daily traffic volume of 14,000 vehicles and Centreville Road has an average daily traffic volume of 15,000 vehicles putting them in the moderate level of traffic per day. 11. Resident 1 sustained no injuries and was returned to the facility that evening. 12. Staff 2 confirmed that no additional interventions were put into place aside from the typical two (2) hour round checks.
Plan of Correction:	Executive Director will ensure the supervision of resident schedules, care, and activities. Detailed attention on specialized needs such as fall prevention and wandering will be immediately implemented. Staff Training of resident specific needs and preventions will be conducted by October 31,2024.
Standard #:	22VAC40-73-560-F
Description:	Based on direct observation, the facility failed to ensure that all records are treated confidentially. Evidence: 1. In the Assisted Living lobby area, a copy of a statement regarding an incident written by Staff 7 and Resident 2?s room number was face down on the ledge of the front desk. 2. In the Assisted Living lobby, a copy of a Charter Member Reservation Agreement dated 08/22/2015 for Resident 3 was face up on the front desk featuring the resident?s name and legal representative contact information. 3. The front desk is in an unrestricted area for both residents and visitors of the facility. The documents could be accessed by reaching over the ledge, or by walking around the desk and entering into the alcove. 4. Photo evidence obtained
Plan of Correction:	Document containing resident information was removed from the Assisted Living Lobby. Executive Director will ensure that all records are treated confidential. All staff training will be on community policy ?Confidentiality in the Workplace?. Staff training will be completed by November 26, 2024.
Standard #:	63.2-1606-A
Description:	Based on document review and staff interview, the facility failed to ensure matters giving reason to suspect the abuse, neglect or exploitation of adults shall be reported immediately upon the reporting person's determination that there is such reason to suspect. Evidence: 1. On 07/27/2024, an internal incident report was documented by Staff 3 for an incident between Resident 2 and Staff 4. 2. The internal incident report states ?[Resident 2?s son] made allegations that CNA raised hand to [Resident 2] and that they don't get along. [Resident 2?s son] also stated that the resident phone is missing threatened legal action and moving out the resident.? 3. Staff 1 stated that a report was not made to Adult Protective Services because the situation was investigated internally, and they deemed it was a misunderstanding
Plan of Correction:	All allegation or suspicion of abuse, neglect or exploration will be timely reported within the time frame of 24 hours will be implemented immediately. Staff training on ?mandated reporter? will be conducted by November 26, 2024.