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. 26, 2024 , Dec. 27, 2024 and Jan. 16, 2025

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 63.2- (1) GENERAL PROVISIONS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Technical Assistance:

License Modification Request

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/26/2024 9:15 AM to 4:00 PM 12/27/2024 10:00 AM to 4:30 PM 01/16/2025 3:00 PM to 3:46 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: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Medication Pass, Safe Secure Unit, Activities, Breakfast and Lunch Meals Additional Comments/Discussion: Facility requested a license modification to convert three additional rooms to Assisted Living, while maintaining the same capacity. Measurements were completed and room modifications were discussed to ensure compliance with applicable standards on 01/16/2025. 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 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 #:	22VAC40-73-220-A
Description:	Based on resident record and staff interview, the facility failed to ensure that the record of private duty personnel employed by a licensed home care organizations contained all the required components. Evidence: 1. In an interview with the LI on 12/27/2024, Staff 1 confirmed that they had one resident that received services from private duty personnel employed by a licensed home care organization. 2. In an interview with the LI on 12/27/2024, Staff 1 stated that they were not sure if an orientation was done because the private duty personnel was done because they were in the building for years. Staff 1 confirmed that no records were held on site for the private duty personnel and stated that they were waiting for records from the agency.
Plan of Correction:	The licensed home care organization will provide records of private duty personnel immediately. The Healthcare Director or designee will audit and maintain of residents utilizing private duty care givers. Healthcare Director will maintain records to ensure requirements of Standard 220-A are compliant and documentation is onsite. A monthly will be conducted to ensure ongoing compliance. This will be completed by March 21, 2025.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, the facility failed to ensure subsequent tuberculosis (TB) evaluations and reports were maintained at the facility and included in the staff record. Evidence: 1. Staff 6?s, hired on 08/27/2019, record did not contain the results of an annual risk assessment. 2. In an interview with the LI on 12/27/2025, Staff 2 confirmed the risk assessment had not been completed.
Plan of Correction:	A TB risk assessment will be completed on Staff #6. An audit of all staff records will be conducted to ensure subsequent TB evaluations and reports are maintained. The Business Office Manager will conduct monthly audits to ensure continued compliance. This will be completed by March 21, 2025
Standard #:	22VAC40-73-310-M
Description:	Based on resident record review and staff interview, the facility failed to ensure there was a written agreement between the hospice provider and the facility when hospice is provided in the facility. Evidence: 1. Resident 2, 3, and 4 received hospice services from Collateral Contact 1. 2. In an interview with the LI on 12/27/2024, Staff 1 confirmed there was not a hospice agreement between Collateral Contact 1 and the facility.
Plan of Correction:	A written agreement between the hospice provider and community will be obtained for Resident number 2, 3, and 4. A 100% audit of all residents? records will be completed to identify outside vendors usage and written provider agreements in community records. The Executive Director will maintain written agreement between community and hospice providers. This will be completed by March 21, 2025
Standard #:	22VAC40-73-450-A
Description:	Based on resident record review and staff interview, the facility failed to ensure a preliminary plan of care was developed on or within seven (7) days prior to admission to address the basic needs of the resident. Evidence: 1. Resident 8 was admitted to the facility on 11/20/2024. 2. Resident 8?s record contained an Individualized Service Plan (ISP) that was signed on 12/02/2024. 3. In an interview with the LI on 12/27/2024, Staff 1 confirmed that the ISP was no completed on or within seven (7) days.
Plan of Correction:	Healthcare Director will ensure that a preliminary plan of care will be developed on or within seven days prior to admission to address the basic needs of the admitting resident. Healthcare Director or designee will conduct weekly audits of all newly admitted residents to ensure compliance. This will be completed by March 21, 2025.
Standard #:	22VAC40-73-700-2
Description:	Based on direct observation and resident record review, the facility failed to ensure ?No Smoking ? Oxygen in Use? signs were posted where oxygen is in use. Evidence: 1. During a tour of the facility on 12/26/2024, the LI observed an oxygen tank sitting in the room of Resident 4. 2. In an interview with the LI on 12/26/2024, Staff 3 confirmed that Residents 1, 2, 3, and 4 currently have active orders for oxygen. 3. Resident 1?s record contains an Office Visit Report that states ?[Resident 1] was sent home with Oxygen 1 L? on 04/02/2024. 4. Resident 2?s record contains Physician Orders that state ?Inhale oxygen at 4 LPM?? 5. Resident 3 and 4?s record?s contain active medication order summaries that listed Oxygen. 6. On 12/26/2024, the LI observed the rooms of Resident 1, 2, 3, and 4 without posted ?No Smoking ? Oxygen in Use? signs. 7. Photo Evidence Obtained.
Plan of Correction:	?No Smoking ? Oxygen in use? signs were purchased and place on the outside of the doors for resident?s number 1, 2, 3, and 4. An audit of all resident?s with oxygen orders will be conducted to ensure that proper signage is displayed. All staff will be educated on standard 700-2The Health Care Director or designee will conduct weekly audits to ensure continued compliance. This will be completed by March 21, 2025
Standard #:	22VAC40-73-860-J
Description:	Based on direct observation and staff interview, the facility failed to ensure that cleaning supplies and other hazardous materials were only stored in a resident?s room if the resident does not have a serious cognitive impairment. Evidence: 1. Resident 5 resides in the safe, secure environment. 2. On 12/26/2024, the LI observed a bottle of ?Redi Wipes Disinfecting? on a table in the unlocked room of Resident 5. 3. In an interview with the LI on 12/26/2025, Staff 2 acknowledged that there were cleaning supplies in a resident?s room on the safe secure environment. 4. Photo evidence obtained.
Plan of Correction:	The cleaning supplies were immediately removed from resident #5 apartment. An audit of all apartments with residents that a serios cognitive impairment will be conducted and any cleaning supplies and other hazardous materials will be removed. All Staff will be educated on standard 860-J. The Health Care Director or designee will conduct weekly audits to ensure continued compliance. This will be completed by March 21, 2025
Standard #:	22VAC40-73-870-B
Description:	Based on direct observation and staff interview, the facility failed to ensure that building was well-ventilated and free from foul, stale, and musty odors. Evidence: 1. The LI noted a foul odor on the safe, secure unit during the building tour on 12/26/2024 and 12/27/2024. 2. In an interview with the LI on 12/27/2024, Staff 1 confirmed that the safe, secure unit has a laundry/linen room and trash room that are on either side and that contributes to the lingering smell.
Plan of Correction:	The Maintenance Director had the trash from the trash room immediately removed. The Maintenance Director or designee will conduct routine walk-throughs to ensure that the building is free from foul, stale, and musty odors. All staff will be educated on the standard 87-0-B. This will be completed by March 21, 2025.