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: May 2, 2023 and May 5, 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:

An unannounced monitoring inspection was conducted on 5/2/23 and 5/5/23. At the time of entrance, 45 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. 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 #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure that each resident is assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare, prior to being admitted into a safe, secure environment. Evidence: A progress note, dated 2/2/22, states that Resident #5 is in memory care. No documentation was found in Resident #5?s record to indicate that she had an assessment of serious cognitive impairment before she was admitted into the safe, secure environment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-1130-A
Description:	Based on observation and interview, the facility failed to ensure that at least two staff members are awake and on duty at all times in each special care unit. Evidence: At approximately 11:12 AM on 5/5/23, only one staff member was observed on the special care unit. Six residents were observed in the living room and dining area. Facility staff reported that the other staff member, assigned to the memory care unit, left the unit to take out the trash.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	Based on documentation, the facility failed to ensure that each staff person submits the results of a tuberculosis risk assessment, on or within seven days prior to the first day of work at the facility. The risk assessment shall be no older than 30 days. Evidence: The tuberculosis risk assessments conducted for Staff #3 (10/2/22) and Staff #4 (6/17/22) were more than 30 days old at their time of hire. Staff #3 was hired on 2/8/23 and Staff #4 was hired on 1/18/23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, the facility failed to ensure that each direct care staff person 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. Evidence: No documentation of current first aid certification was included in the records of: Staff #1 (hired 5/15/19), Staff #2 (hired 2/21/23), Staff #3 (hired 2/8/23) or Staff #4 (hired 1/18/23). Facility staff confirmed that documentation of current first aid certification was not present for Staff #s1-4.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that a risk assessment for tuberculosis is completed annually for each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Tuberculosis risk assessments were more than a year old for: Resident #2 (2/10/22), Resident #3 (2/10/22), Resident #5 (2/10/22), Resident #7 (8/1/21), and Resident #8 (3/1/22). No documentation was provided, during the inspection, to indicate that the tuberculosis risk assessments were completed within the past year for Residents #s 2,3,5,7, and 8.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to ensure that each resident is annually assessed using the uniform assessment instrument. Evidence: The most recent UAI?s included in the records of: Resident #2 (3/11/21), Resident #3 (9/7/21), Resident #5 (1/9/22), and Resident #8 (2/8/22) are more than a year old. No documentation was provided, during the inspection, to indicate that the UAIs were updated within the past year.
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 individualized service plans (ISPs) are reviewed and updated at least once every 12 months. Evidence: The ISPs for Resident #3 (dated 9/7/21), Resident #5 (dated 1/9/22), Resident #7 (dated 8/18/21), and Resident #8 (dated 3/11/22) are more than a year old. No documentation was provided, during the inspection, to indicate that the ISPs were updated within the past year.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-E
Description:	Based on record review, the facility failed to ensure that resident records are kept current and kept in a locked area. Evidence: No notes, documenting the resident?s admission, were included in the records of Resident #1 or Resident #4. Resident #8 was admitted at the facility on 2/28/22 and was later transferred into the memory care unit. Resident #8?s record did not include documentation about when she transferred into the memory care unit. At approximately 4:02 PM on 5/2/23, the room containing resident records was observed to be unlocked and unattended.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area remains locked. Evidence: At approximately 4:02 PM on 5/2/23 the second floor medication cart was observed to be unlocked and unattended.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician?s or other prescriber?s instructions. Evidence: Resident #8?s morning medication administration was observed on 5/2/23. Resident #8?s Guaifenesin?s tablet was crushed. The medication packaging states that it is not to be crushed. Resident #8?s record includes an order, dated 4/3/23, that states that crushable meds may be crushed. No order, was found in the resident record, to document that Resident #8?s Guaifenesin should be crushed.
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 #9?s PRN Hydrocortisone cream (ordered 8/31/21) and PRN Senna (ordered 5/18/21) were not present at the time of the medication cart inspection. Facility staff confirmed that the 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, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area. Evidence: Wound cleansers were found unlocked and unattended in the room of Resident #5, on the memory care unit.
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, from the Department of State Police within 30 days of hiring an employee. Evidence: The record for Staff #2 (hired 2/21/23) was reviewed during the inspection. The criminal record check, included in Staff #2?s record was dated 12/23/21. Staff #2?s criminal record check was not obtained within 30 days of her hire date.
Plan of Correction:	Not available online. Contact Inspector for more information.