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 22, 2024

Complaint Related: Yes

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

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024: 9:15 AM to 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/17/2024 regarding allegations in the areas of: Staffing and Supervision, Resident Accommodations and Related Provisions, and Resident Care & Related Services. Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included a resident room and the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on facility document review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. A referral was submitted to the regional licensing office by Adult Protective Services on 05/17/2024 regarding an incident that occurred on 05/14/2024. 2. Resident 1?s progress notes confirm incident occurred on 05/14/2024, requiring the resident to be sent to the hospital on 05/15/2024. 3. The department did not receive a report from the facility until 05/20/2024.
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 incident reporting and incident investigations will be conducted by July 31, 2024
Standard #:	22VAC40-73-130-B
Complaint related:	Yes
Description:	Based on staff interview, the facility failed to notify the resident's contact person or legal representative when a report is made relating to the resident relating to abuse, neglect, or exploitation, without identifying any confidential information. Evidence: 1. The licensing inspector requested documentation that the facility contacted the resident?s family. 2. Staff 1 stated that the facility did not notify the resident?s family once they were aware of the allegations regarding treatment of Resident 1.
Plan of Correction:	Executive Director will notify resident?s contact person or legal representative when any report of suspected abuse, neglect, or exploitation of resident is made relating to a resident will be implemented immediately. This is effective July 3, 2024.
Standard #:	22VAC40-73-250-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form. Evidence: 1. Staff 2, hired on 06/08/2022, did not have a current annual screening. The last screening was completed 06/10/2022. 2. Staff 1 confirmed that the annual screening was not completed.
Plan of Correction:	An 100% audit of all staff records will be conducted to ensure all staff have tuberculosis risk assessments annually. A monthly review of new hire records will be conducted by the Business Office Manager to ensure compliance in accordance with this standard. The plan of correction will be fully implemented, and noncompliance promptly corrected by July 31, 2024.
Standard #:	22VAC40-73-410-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure acknowledgment of having received the orientation was signed and dated by the resident and, as appropriate, his legal representative, and such documentation was kept in the resident's record. Evidence: 1. Resident 1?s record contained a resident orientation signed by the facility representative and the legal representative of the resident on 03/28/2024. 2. Staff 1 confirmed the resident orientation was signed by the POA and not the resident.
Plan of Correction:	An audit of all resident files will be conducted and resident orientation to the community will be conducted. Executive Director will ensure acknowledgment of having received the orientation was signed and dated by the resident and, as appropriate, his legal representative, and such documentation was kept in the resident's record. This will be completed by July 31, 2024
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was 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 1?s record contained an ISP signed by the facility on 04/04/2024. 2. Staff 1 confirmed the signed ISP was not in the resident?s record.
Plan of Correction:	450-E 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 July 31, 2024.
Standard #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on resident record review, resident interview, staff record review and staff interview, the facility failed to ensure the health, safety, and well-being of the residents. Evidence: 1. Resident 1 stated that Staff 2 was very rough with Resident 1 and would throw Resident 1 around, leading to a fall during transferring on 05/14/2024. Resident 1 shared that Staff 2 wouldn?t let her have her phone or call bell after the incident on 05/14/2024. Resident 1 said ?I think she hated me? and she acted like ?she didn?t even want to touch me sometimes.? Resident 1 stated that other interactions with Staff 2 included raised voices and pushing her in wheelchair with it? banging? around. Resident 1 alleges that other staff, including Staff 2 and 4, are also ?not so nice? sometimes. 2. Resident 2 stated that staff are not always gentle because they are rushing. 3. Staff 2?s record contained an Employee Corrective action form dated 09/29/2023 stating ?Left residents in [rooms of Residents 3, 4, 5, and 6] very wet. All resident was drench in urine. Resident in [room of Resident 6]. She was very rough with the resident and did not change the resident. The homecare aide took care of the resident in [room of Resident 6] because the CNA was very rough.? 4. Staff 2?s record contained a management investigation signed on 05/22/2024 indicating ?During an interview with APS, employee admitted using improper techniques transferring resident. Employee admitted to not providing resident with communication device when asked for by resident.? 5. Staff 2?s record contained a termination form dated 05/22/2024 listing the type of offense as ?Failure to Meet Performance/Behavior Expectations.? 6. Staff 1 confirmed that Staff 2 was terminated due to the incident on 05/14/2024, along with previous disciplinary concerns.
Plan of Correction:	Executive Director will ensure the health, safety, and well-being of the residents by promptly reviewing all incidents and internal investigations. Staff Training will be conducted on ?Safe Resident Handling? by July 31,2024.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on resident and staff interview, the facility failed to ensure at the time the medication is administered, the facility documented on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements. Evidence: 1. Resident 1 has a prescription for Lidocaine 5% patch ordered on 05/15/2024. The order states ?Apply 1 patch topically to affected area every morning and remove in 12 hours at bedtime for pain.? 2. Resident 1 stated that a patch was applied the evening of 05/21/2024, around 6pm, and another patch put on in the morning of 05/22/2024 around 8:00am. 3. Resident 1 contacted Staff 1 and Staff 3 concerned about the possible medication error and asked that the patch be removed on 05/22/2024. 4. Staff 3 removed the patch and contacted Staff 5 to see if the patch was applied on 05/21/2024. Staff 3 stated that Staff 5 was unaware that the medication was routine, and not PRN, and applied the patch per the resident?s request on the evening of 05/21/2024. 5. The May 2024 MAR documents that a patch was ?OFF? at 8:00 pm by Staff 5 on 05/21/2024 and ?ON? at 8:00 AM by Staff 3 on 05/22/2024. 6. Staff 3 confirmed there was no documentation on the MAR or in the progress notes that the additional patch was applied on 05/21/2024 or removed on 05/22/2024. 7. Staff 3 stated the documentation would be completed before the end of their shift.
Plan of Correction:	Health Care Director will audit medication administration to ensure medication is administered per prescribers? orders and documented on the residents? medication administration record. Training will be conducted with all MedTechs and LPNs on medication administration/documentation policies and procedures. This will be completed by July 31, 2024.
Standard #:	22VAC40-90-30-B
Complaint related:	No
Description:	Based on staff record review and staff interview, the facility failed to ensure all applicants for employment at assisted living facilities and adult day care centers provided the facility with a sworn statement or affirmation. Evidence: 1. Staff 2?s, hired on 06/08/2022, record did not contain a signed sworn statement or affirmation. 2. Staff 1 stated ?We do not have the initial sworn statement.?
Plan of Correction:	An audit of all employee files will be conducted to ensure all staff have completed a sworn statement. Business Office Manager will to ensure all applicants for employment at assisted living facilities provided the facility with a sworn statement or affirmation prior to employment. This will be completed by July 31,2024.