VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tribute at One Loudoun, LLC
20335 Savin Hill Drive
Ashburn, VA 20147
(571) 252-8292

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: March 9, 2020 and March 10, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 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. 22VAC40-80 THE LICENSING PROCESS.

Comments:

An unannounced renewal study was conducted on 3/9/2020 and 3/10/2020. At the time of entrance 97 residents were in care. The sample size consisted of 10 resident records, five staff records, and four individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 2/19/2019 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including fitness with Chuck, daily chronicle, and power brain. Medication administration was observed. Possible violations were discussed at the exit interview which was held 3/12/2020. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based upon a review of resident records, the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: Resident #5 and Resident #6 reside in a safe, secure environment. The six month reviews of appropriateness of continued residence in the safe, secure environment were not found in the resident's records. The six month review for Resident #5 should have been completed in September 2019. The six month review for Resident #6 should have been completed in April 2019.
Plan of Correction:	Memory care residents will be re-evaluated six months after move-in for appropriate safe and secure environment and then annually. Memory care coordinator to ensure complete of evaluations and that evaluations are placed in resident's charts.
Standard #:	22VAC40-73-440-A
Description:	Based upon a review of resident's records, the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: The Uniform Assessment Instrument (UAI) for Resident #7, who was admitted on 3/4/2020 was completed 3/10/2020. The UAI for Resident #8, who was admitted on 3/6/2020, was completed on 3/10/2020. The UAI for Resident #3 was last completed 2/8/2019 and is overdue for review.
Plan of Correction:	Uniform Assessment Instruments (UAIs) will be completed by the evaluator upon face to face evaluation of resident prior to move in. The direct care coordinator will ensure completion of UAIs and that UAIs are place in the charts. An audit of resident files to ensure UAIs are current and in the files will be completed by 4/30/2020.
Standard #:	22VAC40-73-450-F
Description:	Based upon a review of resident records, the facility failed to ensure individualized service plans shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Evidence: The Individualized Service Plan (ISP) for Resident #1 was last updated 1/18/2019. The ISP for Resident #2 was last updated 2/17/2019, and the ISP for Resident #6 was last updated 1/10/2019.
Plan of Correction:	Individualized Service Plans (ISPs) will be completed upon move in and updated at least every 12 months or with an acute condition change. ISPs will be completed by evaluator and approved by administrator. Direct care coordinators will ensure completed ISPs are in the resident's charts.
Standard #:	22VAC40-73-700-2
Description:	Based upon physical observation of the building, the resident's rooms, and review of records, the facility failed to post "No Smoking-Oxygen in Use" signs and enforce the smoking prohibition in any room of a building where oxygen is in use. Evidence: On 3/9/2020, Licensing Inspector observed oxygen in the rooms of two residents. "No Smoking-Oxygen in Use" signs were not posted for those two residents.
Plan of Correction:	All residents with oxygen will have a "no smoking-oxygen in use" sign on their doors. Nurse will check for signage daily and chart findings.