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. 29, 2025 and 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 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 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 12/15/2024 regarding allegations in the area(s) of: 1. Admission, Retention, and Discharge of Residents 2. Resident Care and Related Services 3. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/29/2025: 10:55 AM to 2:40 PM 01/30/2025: 10:00 AM to 12:00 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: 107 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Lunch Meals, Buildings & Grounds Additional Comments/Discussion: N/A 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: 1. Admission, Retention, and Discharge of Residents 2. Resident Care and Related Services 3. Resident Accommodations and Related Provisions 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 #:	22VAC40-73-50-B
Complaint related:	No
Description:	Based on facility document review and staff interview, the facility failed to ensure that written acknowledgement of the receipt of the disclosure by the resident or the resident?s legal representative was retained in the resident?s record. Evidence: 1. Resident 1?s, admitted 11/04/2024, record did not contain written acknowledgement of the receipt of the disclosure by Resident 1 or Resident 1?s legal representative. 2. In an interview with the LI on O1/19/2024, Staff 1 acknowledged there was not a disclosure form in the record.
Plan of Correction:	ED or designee will ensure all future residents/legal representatives receive and acknowledge the disclosure. The Disclosure will be maintained in the resident record.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on resident record and staff interview, the facility failed to ensure that a report was sent to the regional licensing office within 24 hours for any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Resident 1?s record contains a progress note, dated 11/07/2024, written by Staff 4 that states ?Resident called 911 and stated `[Resident 1] was being held against [Resident 1?s] will, wanting to harm himself.? 2. In an interview with the LI on 01/29/2025, Staff 4 stated that a sheriff arrived and was escorted to Resident 1?s room. Staff 4 confirmed that Resident was observed unharmed, with additional injury or incidents to report. 3. In an interview with the LI on 01/29/2025, Staff 1 confirmed that an incident report was not written or reported.
Plan of Correction:	ED or designee will ensure that licensing office receives notification of any incident where an outside agency was called by resident, staff or family member. Notification will include all required information.
Standard #:	22VAC40-73-340-B
Complaint related:	No
Description:	Based on facility document review, resident record review, and staff interview, the facility failed to ensure that a determination has been made that a facility can meet the needs of the individual based upon the physical examination report prior to admitting the resident. Evidence: 1. In an interview with the LI on 01/29/2025, Staff 1 stated that they were unaware of Resident 1?s behaviors until after Resident 1?s admission on 11/04/2024. 2. In a phone interview with the LI on 01/29/2025, Staff 3 stated that they completed Resident 1?s admission assessment at [Hospital]. Staff 3 stated that they spoke to the specialists regarding Resident 1?s care needs, including having behaviors that resulted in the furniture needing to be removed from the hospital room. 3. Resident 1?s record contained a Mental Health Screening Determination Form dated 10/22/2024. Under ?Part II. Psychosocial and Behavioral History, the first question states ?If there are indication of mental health problems within the past 6 months, has the referring party provided a documented psychosocial and behavioral history that describes the prospective resident?s psychological, social, emotional, and behavioral functioning?? The box ?No? is circled. The second question stated, ?Did the facility consider the information contained in the psychosocial and behavioral history in making a decision about whether the facility can meet the needs of the individual?? The answer was blank, including whether it was reviewed and the date of the review. 4. Resident 1?s record contained hospital discharge paperwork dated as faxed on 10/29/2024. The hospital discharge paperwork stated ?KICKED OUT OF [Another Facility]/DEMENTIA/COMBATIVE]? under the reason for admission. 5. Resident 1?s record contained a Report of Physical Examination with multiple attached psychiatric progress notes dated between -10/07/2024 and 10/24/2024 containing documentation of resident?s behavioral issues including irritability, delusions, agitation, refusals of care, and confusion. 6. Resident 1?s record confirmed a ?lifetime Memoir? questionnaire. The following boxes were checked for that the resident?s typical disposition: ?Pleasant, anxious, argumentative, angry, confused negative and other.? Under other, the written text stated, ?Moods change day-by-day.? ?Yes? box was checked for the question, ?Does the resident exhibit any behaviors that should be noted such as reluctance to bathe, change clothes, anxiety, etc?? The questionnaire lists the residents triggers as ?Delayed response?dirty home?foul odors in home.? 7. In an interview with the LI, Staff 1 stated that they are not sure who reviewed that information or when it was reviewed and/or received. 8. In an interview with the LI on 01/29/2025, Staff 1 confirmed the resident was provided a notice of discharge on 11/08/2024. 9. Resident 1?s record contained a Discharge Notification and Statement that indicated the reason for discharge was ?Unable to meet Resident needs nor family.? 10. In an interview with the LI on 01/29/2025, Staff 1 provided email communication sent by Staff 1 to Resident 1?s legal representative on 11/08/2024. The letter states that the Resident 1 ?Presents an immediate serious risk to the health, safety, or welfare of himself or others? with the next line stating ?Resident has flooded [Resident 1?s] room, barricaded himself in [Resident 1?s] room, tore [Resident 1?s] room apart, removed all furniture to hallway, refuses medications and assistance, calls 911, disruptive behaviors in the community ongoing.?
Plan of Correction:	The ED or designee will review all admission paperwork, including any psychosocial/mental health history, prior to approval for placement in the community to ensure needs can be met. All current residents with mental health/behaviors are being monitored monthly or as needed by psych. All residents who exhibit mental health behaviors will be referred to psych services for an evaluation. Evaluations will be maintained in the resident records.
Standard #:	22VAC40-73-450-A
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure that a preliminary plan of care developed to address the basic needs of the resident that adequately protects his health, safety, and welfare was developed on or within seven (7) days prior to the day of admission and signed by the resident or his legal representative. Evidence: 1. Resident 1?s, admitted 11/04/2024, record contains an Individualized Service Plan (ISP) dated 10/20/2024. The ISP was not signed by Resident 1 or Resident 1?s legal representative. 2. In an interview with the LI on 01/29/2024, Staff 1 acknowledged that Resident 1?s ISP was completed 14 days prior to admission.
Plan of Correction:	ED or designee will ensure that the initial plan of care is signed by the Resident/legal representative. HWD will audit all current residents records to ensure current care plans are signed/received or acknowledged as approved by legal representative and documented in the record.
Standard #:	22VAC40-73-560-C
Complaint related:	No
Description:	Based on resident record and staff interview, the facility failed to ensure that any physician?s notes and progress reports in the possession of the facility shall be retained in the resident?s record. Evidence: 1. In a phone interview with the LI, Staff 3 confirmed that Resident 1 was receiving psychiatric services, and had documented information regarding care and behaviors on paper logs and paper progress notes. 2. In an interview with the LI, Staff 1 provided Resident 1?s record. Resident 1?s record did not contain any physician progress notes or paper logs, Staff 1 stated that there was no additional documentation available.
Plan of Correction:	The ED or designee will ensure that all current and former resident records including physician notes/progress notes. They will be maintained in the resident records or discharged resident files.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on facility document review, resident record review, and staff interview, the facility failed to ensure the facility's own medication management plan was implemented. Evidence: 1. Resident 1?s, admitted 11/04/2024, had signed orders for Nuplazid 34 MG dated 10/28/2024 and hospital discharge orders Trazadone 100 mg dated 11/04/2024. 2. Resident 1?s record contains communication from [Pharmacy] that states ?Please clarify `Patient Own Med? at bedtime. Thank you.? 3. Resident 1?s Medication Administration Record (MAR) indicates that both Nuplazid and Trazadone were not administered 11/04/2024 through 11/07/2024. Both medicines were administered on 11/08/2024. 4. The facility?s medication management plan contains a section titles ?Med 30 ? Medication Errors.? The policy states ?A medication error is defined as?6) missed dose. 7) Not initiating an order.? The procedure states the following: ??2) The resident?s prescribing physician is immediately notified of the medication error?3) Document and follow instructions given by the resident?s physician?6) Enter a narrative note on resident status during every shift for 72 hours after a medication error occurs?7) The responsible party is notified of the error.? 5. Resident 1?s record did not contain any of the required information including confirmation of notification to the physician and any physician instructions, narrative notes for 72 hours after a medication error, or notification to the responsible party. 6. In an interview with the LI, Staff 1 acknowledged that the admission orders were not initiated, and stated that maybe the medication was not provided by the family. Staff 1 confirmed there was no additional documentation available regarding additional orders, progress notes, or communication regarding the medication error.
Plan of Correction:	The HWD will ensure that the Medication Management Plan is followed. The HWD will inservice all med techs on the Medication Management Plan by April1, 2025.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident record and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s orders. Evidence: 1. Resident 1?s record, admitted 11/04/2024, contains a Report of Resident Physical Examination, dated 10/28/2024, with a medication list that contains an active order for ?Patient Own Me (PATIENT?S OWN)? that states ?See Detail.? On a separate page, attached to the Report of Resident Physical Examination, ?NUPLAZID 34 MG CAPSULES? is typed next to ?Patient?s Own Medication (PATIENT?S OWN MEDICATION).? 2. Resident 1?s record contains hospital discharge medication orders, dated for ?Nuplazid 1 MG? that state ?34 mg by mouth at bedtime? and ?Trazodone 100 mg.? 3. Resident 1?s Medication Administration Record (MAR) for November 2024 lists an order for Nuplazid 34 MG, started on 11/08/2024, that states ?TAKE ONE CAPSULE BY MOUTH EVERY NIGHT AT BEDTIME FOR [Diagnosis]?. The MAR documents Nuplazid as not being administered 11/04/2024 through 11/07/2024. 4. Resident 1?s MAR for November 2024 lists an order for Trazadone 100 MG, started 11/08/2024, that states ?TAKE ONE TABLET BY MOUTH EVERY NIGHT AT BEDTIME FOR MOOD/SLEEP.? Resident 1?s MAR documents Trazadone as not being administered 11/07/2024. 5. Resident 1?s record contains a signed order, dated 11/11/2024, that states ?Stop Nuplazid 34 MG)? and ?Start Trazodone 100 MG.? 6. In an interview with the LI on 01/30/2024, Staff 1 and 2 acknowledged both Nuplazid and Trazodone were included on the admission orders. Staff 1 stated that they did not know why the medication was not administered 11/04/2024 through 11/07/2024.
Plan of Correction:	The HWD will ensure that all medications are administered according to the physicians or other prescriber instructions. Proper medication administration procedures will be reviewed with all med techs during the Med Tech Refresher at least 1 time a year.