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: Oct. 18, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

? 63.2-1808- A.17: Each person who becomes a resident of the assisted living facility is accorded respect for ordinary privacy in every aspect of daily living.

Comments:

Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 10/11/2024 regarding allegations in the area(s) of: resident accommodations and related provisions. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/18/2024: 8:50 AM to 12:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast meal on the 1st floor. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 #:	22VAC40-73-290-B
Complaint related:	No
Description:	Based on direct observation and staff interview, the facility failed to ensure that the current on-site person in charge was posted in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entering the building in the Independent Living lobby, the LI observed the Designated Staff Person in Charge was posted as Staff 1. Staff 3 was sitting at the desk in the front lobby. Staff 3 stated that they had not seen Staff 1 but that may be because they were on the Assisted Living side of the facility and pointed the LI in the right direction. The LI went to the Assisted Living side and knocked on the office door of Staff 1 with no answer. The LI approached Staff 4 in the hallway. Staff 4 stated that Staff 1 was not in the building yet, but they could get another director. Staff 4 attempted to call the other director and Staff 1 by phone but could not get ahold of them. 2. Staff 1 arrived about 40 minutes later. In an interview with the LI on 10/18/2024, Staff 1 confirmed that whoever is up front in the Independent Living lobby typically updates Designated Person in Charge sign. 3. Photo evidence obtained.
Plan of Correction:	The facility will ensure that the current on-site person in charge was posted in a place in the facility that is conspicuous to the residents and the public. The on-site person in charge will be responsible for ensuring the posting is accurately indicating the on-site person in charge on a daily basis. All managers will be trained on the On-site person process. The Executive will monitor the on-site person in charge posting during his/her morning walk-through of the community daily. This will be completed by March 31, 2025.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on resident record review, staff interview, and resident interview, the facility failed to ensure that the next of kin, legal representative, or the designated contact person were notified as soon as possible (but no later than 24 hours from the situation) when the resident suffers a serious accident, injury, illness or medical condition. Evidence: 1. Resident 1?s, admitted 06/13/2024, record contains progress notes that state the following: a. On 07/13/2024, ?Resident call 911 on 07\13\24 anout [sic] 4pm and said [Resident 1] is having trouble breathing and think [Resident 1] has a fever ,911 came and check resident?911 take resident to [Hospital Name.] b. On 08/10/2024, ?Resident call 911, but did not let any of the staff know about it until the police came in the building?they are taking [Resident 1] to [Hospital Name].? c. On 10\06\2024, ?ON 10\6\24 Resident came back from the hospital?? 2. There is no documentation in the progress notes, or record, that the emergency contact was notified. 3. Resident 1?s record contains a document titled ?Resident Face Sheet? that lists the same two individuals as the Emergency 1st Contact, Emergency 2nd? Contact, and the Power of Attorney. The form states ?Please provide the names and addresses of your children, brothers, sisters, or nearest relatives and friends. Please give phone numbers on all persons listed. If you need more space, please use the back of this page. Please list in the order you want them contacted in an emergency.? 4. In an interview with the LI on 10/18/2024, Resident 1 stated ?They didn?t know where I was? when talking about the most recent hospital admission. 5. In an interview with the LI on 10/18/2024, Staff 1 said that the typical policy is that if the resident is unable to make decisions, then the contact is notified. Staff 1 stated that if they can make decisions it is up to the resident to contact.
Plan of Correction:	The facility will ensure that the next of kin, legal representative, or the designated contact person were notified as soon as possible (but no later than 24 hours from the situation) when the resident suffers a serious accident, injury, illness or medical condition and document the contact in resident?s cart. All Medication Technicians will be trained on timely and proper notifications of serious resident incidents. The Healthcare director will review and monitor documentation of all serious accidents, injury, illness or medical conditions daily. This will be completed by March 31, 2025.