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

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Aug. 18, 2021 and Sept. 30, 2021

Complaint Related: No

Areas Reviewed:
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
A non-mandated self-report inspection was initiated on 8/18/2021 and concluded on 9/30/2021. A self-reported incident was received by the department regarding allegations in the area of resident care. The administrator was contacted by telephone and by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation.

The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.


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 #: 22VAC40-73-440-A
Description: Based upon a review of records, the facility failed to ensure that a UAI shall be completed whenever there is a significant change in the resident?s condition.
Evidence: 1.Resident # 1 lives in a secured care unit due to a serious cognitive impairment. The Uniform Assessment Instrument (UAI) for Resident #1 dated 6/21/2021 documents that Resident #1 is disoriented to time, place, and person some of the time. The UAI for Resident #1 indicated that the resident?s behavior pattern is ?wandering/passive less than weekly.?
The progress notes document that on the following dates, Resident #1 exhibited the following disruptive or aggressive behaviors:
A. 7/5/2021 at approximately 3:42 pm, resident noted to be ?very close and affectionate towards male residents and gets very upset when redirected, she is refusing care and meals if she is fixed to a male resident.?
B. 7/6/2021 at approximately 9:10pm, ?resident noted wants to be close to male residents, private aid redirects her.?
C. 7/7/2021 at approximately 6:04 pm, ?Resident engaged with PDA (private duty aide), ate her meals, and took her schedule meds, notes to still chase male resident but able to be redirected by private duty. POA (power of attorney) updated, team aware to monitor resident?s whereabouts.?
D. 7/9/2021 at approximately 12:47 pm, ?Resident noted wearing T-shirt as a skirt at breakfast time, when PDA arrived she helped resident to changed clothes, resident love to be closer and she want to sat down on male resident lap and private caregiver redirects her and offered her some drinks.?
E. 7/11/2021 at approximately 9:06 pm, ?Staff reported to nurse that resident was witnessed to be engaged in activity of sexual nature with another resident, residents were separated and redirected.?
F. 7/25/2021 at approximately 11:43 am, ?Resident was observed approaching another female resident and agitating her, she then slapped her hand.?
G. 8/3/2021 at approximately 4:38 pm, ?Staff reported to writer that resident came inside Room 2036, the sister found out that resident was inside the room kissing the other resident.?
H. 8/8/2021 at approximately 3:59 pm ?Resident?s sister Sally came to visit around 3:10pm, after not finding resident in TV area or her suite she proceeded to walk the lobby and heard some moaning noise coming near Suite 2007, she then saw the resident?s shoe near 2007 door and observed her sister with male resident in bed having intercourse.? The progress notes for this incident indicate ?resident unable to recall episode, other male resident was redirected.?
I. 8/12/2021 at approximately 4:08 pm ?Resident continues to approach other male residents, difficult to redirect.?
J.8/24/2021 at approximately 6:02pm ?Resident was in verbal argument with another resident, the other resident struck out her fist and made contact to the chest area. Resident does not have any marks to chest area.?

Due to extensive information, additional evidence is documented on a seperate form.

Plan of Correction: The Uniform Assessment Instrument (UAI) for Resident #1 and Resident #2 were updated to reflect the significant change in the resident's condition. The Resident Services Director (RSD), or designee will ensure the UAI is updated when there is a significant change upon review for all residents.

Standard #: 22VAC40-73-450-F
Description: Based upon a review of records, the facility failed to ensure that individualized service plans shall be reviewed and updated as needed as the condition of the resident changes.
Evidence: 1. The Individualized Service Plan (ISP) dated 7/14/2021 for Resident #1 indicates under the identified need of psychosocial services ?resident has current or history of wandering that does not jeopardize safety. Current or history of wandering within the residence or facility and may wander outside but does not jeopardize health of safety (of self or others). May have behavior management in place?; services are to be provided by caregiver and direct care staff in the resident?s apartment and throughout the community, and the goal is that ?resident will maintain or maximize current level of functioning with wandering.?
The progress notes for Resident #1 would indicate Resident #1 current plan for addressing the psychosocial unmet need, should be updated due to change in Resident #1 condition. The progress notes for the following dates for Resident #1 indicate that Resident #1 has exhibited aggressive/disruptive behaviors that jeopardize herself and other residents:
A. 7/5/2021 at approximately 3:42 pm, resident noted to be ?very close and affectionate towards male residents and gets very upset when redirected, she is refusing care and meals if she is fixed to a male resident.?
B. 7/6/2021 at approximately 9:10pm, ?resident noted wants to be close to male residents, private aid redirects her.?
C. 7/7/2021 at approximately 6:04 pm, ?Resident engaged with PDA (private duty aide), ate her meals, and took her schedule meds, notes to still chase male resident but able to be redirected by private duty. POA (power of attorney) updated, team aware to monitor resident?s whereabouts.?
D. 7/9/2021 at approximately 12:47 pm, ?Resident noted wearing T-shirt as a skirt at breakfast time, when PDA arrived she helped resident to changed clothes, resident love to be closer and she want to sat down on male resident lap and private caregiver redirects her and offered her some drinks.?
E. 7/11/2021 at approximately 9:06 pm, ?Staff reported to nurse that resident was witnessed to be engaged in activity of sexual nature with another resident, residents were separated and redirected.?
F. 7/25/2021 at approximately 11:43 am, ?Resident was observed approaching another female resident and agitating her, she then slapped her hand.?
G. 8/3/2021 at approximately 4:38 pm, ?Staff reported to writer that resident came inside Room 2036, the sister found out that resident was inside the room kissing the other resident.?
H. 8/8/2021 at approximately 3:59 pm ?Resident?s sister Sally came to visit around 3:10pm, after not finding resident in TV area or her suite she proceeded to walk the lobby and heard some moaning noise coming near Suite 2007, she then saw the resident?s shoe near 2007 door and observed her sister with male resident in bed having intercourse.? The progress notes for this incident indicate ?resident unable to recall episode, other male resident was redirected.?
I. 8/12/2021 at approximately 4:08 pm ?Resident continues to approach other male residents, difficult to redirect.?
J. 8/24/2021 at approximately 6:02pm ?Resident was in verbal argument with another resident, the other resident struck out her fist and made contact to the chest area. Resident does not have any marks to chest area.?

Due to extensive information additional evidence is found on a seperate form.

Plan of Correction: The Individualized Service Plan (ISP) for Resident #1 and Resident #2 were updated to reflect the change of condition. The Resident Services Director (RSD), or designee, will ensure the ISP is updated when there is a significant change upon review for all residents.

Standard #: 22VAC40-73-460-H
Description: Based upon a review of records, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with dressing.
Evidence:
1. According to progress notes for 7/9/2021 for Resident #1 ?resident noted wearing T-shirt as her skirt at breakfast time? and on 8/5/2021 the progress note stated ?staff reported resident walking on the hallway naked yesterday and today.?
2. The Uniform Assessment Instrument (UAI) dated 6/21/2021 indicates that Resident #1 needs human help and supervision with dressing.
3. The Individualized Service Plan (ISP) for Resident #1, dated 7/14/2021, documents that Resident #1 as an identified need of dressing, the description of the services to be provided indicate that the ?resident can dress/undress and select clothing but may need to be reminded/supervised?, the person who will provide services is documented on the ISP as the caregiver and/or direct care staff, and the services will be provided in the resident?s apartment and the goal listed on the ISP is that ?resident will maintain and/or maximize current level of functioning with dressing.?

Plan of Correction: The community will ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with dressing. The Resident Services Director (RSD), or designee, will ensure personal assistance and care are provided; including dressing.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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