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: Feb. 10, 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 63.2- (1) GENERAL PROVISIONS 63.2- (16) PROTECTION OF ADULTS AND REPORTING 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 01/28/2025 regarding allegations in the area(s) of: Resident Care and Related Services 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: 02/10/2025 10:30 AM to 01:10 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: 105 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: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lobby, Bistro Area, Dining Additional Comments/Discussion: Additional Off-Site Interviews Conducted. This inspection was completed in conjunction with Loudoun County Adult Protective Services. 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: Resident Care and Related Services. 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure that any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident is reported to the regional licensing office within 24 hours. Evidence: 1. On 01/29/2025, Staff 1 notified the department of an incident report via email. The incident report states ?APS Worker [Collateral Contact 2] reported that there had been a report of bruising and possible abuse. APS requested to speak to [Resident 1] ?? 2. In an interview with the LI, Staff 1 confirmed that they were notified about the injury on 01/24/2025 by Collateral Contact 1. Staff 1 confirmed that the report was not submitted within 24 hours to the regional licensing office.
Plan of Correction:	The Executive Director or designee will inform the state inspector via email a report of any incident that negatively affects a resident within 24 hours. Inservice completed by Regional HWD and SVPO of Compliance on Reporting Incidents 4/16/25.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed annually. Evidence: 1. Resident 1?s, admitted 08/29/2023, record contains a UAI dated 08/22/2023. 2. In an interview with the Licensing Inspector on 02/10/2025, Staff 1 and 2 stated that there was not another UAI completed or available. Staff 1 and 2 confirmed that the UAI dated 08/22/2023 is the most recent copy.
Plan of Correction:	Resident UAI will be updated by 4/25/25 by the HWD or designee. All resident records will be reviewed to ensure that UAIs have been completed in the last year or updated accordingly by the HWD or the designee by 4/30/25. HWD will monitor the UAIs to ensure accuracy and compliance.
Standard #:	63.2-1606-A
Complaint related:	Yes
Description:	Based on resident interview, collateral contact interview and staff interview, the facility failed to ensure matters giving reason to suspect the abuse, neglect or exploitation of adults shall be reported immediately upon the reporting person's determination that there is such reason to suspect. Evidence: 1. In an interview with the Licensing Inspector on 02/10/2025, Staff 1 stated that on 01/24/2025, Collateral Contact 1 asked Staff 1 to talk to Resident 1 because Resident 1 had red marks on their arms. Staff 1 stated that Collateral Contact 1 stated something happened to Resident 1 ?down there? while pointing to the pelvic area. 2. In an interview with the Licensing Inspector on 02/10/2025, Staff 1 confirmed that they did not report the suspicion of abuse to Adult Protective Services.
Plan of Correction:	Executive Director or designee will report any report of suspicion of abuse or neglect to APS and the state licensing inspector in appropriate time guideline. Executive Director will complete an in service on reporting suspicion of abuse or neglect by 4/30/25.