VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Jan. 30, 2025

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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 01/08/2025 regarding allegations in the area(s) of: Personnel and Staffing and Supervision. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/30/2025 1:30 PM to 4:00 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: 106 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1* Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities and Meals. Additional Comments/Discussion: One interview conducted with an additional resident that refused. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were staffing and supervision. A violation notice was 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 #:	22VAC40-73-280-B
Complaint related:	Yes
Description:	Based on staff interview, the facility failed to ensure a written staffing plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care was maintained. Evidence: 1. On 01/30/2025, the LI requested a copy of the written staffing plan. Staff 1 stated that the facility does not have a written staffing plan that includes the specific number of direct care staff needed. Staff 1 did not provide a copy of the written staffing plan. 2. In an email to the LI on 02/11/2025, Staff 1 provided a policy titled ?GP12 - Staffing, Emergency Training, CPR and First Aid Training? dated 06/01/2024. The policy did not include the specific type and number of direct care staff needed to meet the routine direct care and identified special needs for the residents.
Plan of Correction:	The ED or the designee, will at a minimum, quarterly, review the resident acuity to determine staffing needs for each shift on AL. At a minimum there will be 4 caregivers and 2 med techs on 1st and 2nd shift and at least 2 caregivers and 1 med tech on third shift. The ED or designee, will at a minimum, quarterly, review the resident acuity on MC to determine staffing needs for each shift. At a minimum MC will meet the staffing ratio standard in2 2VAC40-73-1130.
Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on resident record review, staff interview, and facility document review, the facility failed to ensure prompt response to care as determined by circumstance. Evidence: 1. In an interview with the LI on 01/30/2025, Staff 1 stated there is not a policy or written requirement for call bell response times. Staff 1 stated that they try to answer them as timely as they can, and the goal is to answer within 15 minutes. 2. In the resident handbook on page 3, the Resident Services information states the following under ?what do I do if I?m waiting for a response to my pendant?? 3. During an on-site review of the call-bell records for January 2025, the LI observed multiple call bell responses totaling 60+ minutes in the evening hours between 3:00 PM and 7:00 PM. 4. In an interview with the LI, Staff 1 and 2 confirmed that the dinner time is 4:30 PM to 6:00 PM with a lot of residents wanting to head to dinner early. 5. In an email to the LI on 02/24/2025, the administrator provided the call bell response time for 12/24/2024 to 01/08/2025. There were 15 responses over 15 minutes. 6. In an interview with the LI on 01/30/2025, Resident 1 stated that the facility needs more help, and that there was one night Resident fell out of bed and waited a long time for someone to come. Resident 1 stated that they believe the average response time is 20-30 minutes. Resident 1 stated they believed the facility doesn?t prioritize and gave the example that they will come in to turn the pendent off, take out the trash, and then aid. 7. In separate interviews with the LI on 01//30/2025, both Staff 3 and 4 confirmed that the facility generally has three to four direct care staff at any time. Staff 3 and 4 said that when they have three care staff, they are short, and the work is difficult to answer everyone timely and safely. Staff 3 stated that they have heard residents complain about the wait time. 8. In the resident council notes for August 24, there is a question documented conversation between Resident 3 and Staff 1. It goes as follows: a. Resident 3: ?Is there a shortage of help overnight because it seems dire as many people need help getting back in bed or going to the restroom.? b. Staff 1: ?We meet the state standard, and we have enough staff, and we are constantly hiring staff dur to turnover. Is there a particular time this occurs and then I can look into it.? 9. In the resident council notes for August 24, there is a question documented conversation between ?Family of [Room Number]? and Staff 1. It goes as follows: a. ?Family of [Room Number]?: ?The rule book says there is a 15-minute callback when the button is pushed. Is there anyway to tell the difference between an emergency and something like a lost remote.? b. Staff 1: There?s no way to differentiate. c. ?Family of [Room Number]?: When is it time to revaluate the system as the wait time exceeds by at least 4x d. Staff 1: It is something to investigate the time logs. It is hard to find staff just to come in for the 2 hours it is before and after meals. e. ?Family of [Room Number]?: When does it become unfair for residents to wait 2 hrs- when is it responsible to reevaluate the system. 10. In the resident council notes for December 24, there is a question documented conversation between the residents and staff. It goes as follows: a. Resident 1: ?I am new here, but it has been hard to get someone to help me in the morning, this morning I didn?t even call someone I just got myself out of bed and ready. b. Staff 5: ?I will look into call times? 11. In an interview with the LI on 01/30/2025, Staff 2 stated that the pendants must be physically reset and that can contribute to long call bell times. Staff 2 gave an example that if a call bell is taken with a resident while they are on leave, the facility is unable to reset the button until it is back in the building.
Plan of Correction:	Ed or designee will monitor call bell system periodically to ensure that call bells are answered timely to meet the needs of the residents. March 18,2025.