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: March 20, 2025

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 63.2- (1) GENERAL PROVISIONS 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

Technical Assistance:

Resident Records ? Access by Residents and/or Legal Representatives

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/20/2025 8:15 AM to 6:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: Medication Pass, Meals, and Activities on Both Assisted Living and Memory Care Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-210-G
Description:	Based on staff record review and staff interview, the facility failed to ensure that documentation of training received included the number of hours of training and was kept by the facility in a manner that allows for the identification of the individual staff member. Evidence: 1. The LI requested the annual training documentation for Staff 11, 12, 13, and 14. 2. Staff 1 provided a transcript for Staff 11, Staff 12, Staff 13, and Staff 14 from Relias. The transcript did not include the number of hours of training. 3. In an interview with the LI on 03/20/2025, Staff 3 confirmed the transcript did not include the number of hours of training.
Plan of Correction:	Executive Director and or design will print out certificates from Relias monthly and maintain certificates in binder separated by individual staff members Completed by 5/5/25
Standard #:	22VAC40-73-310-M
Description:	Based on facility document review, resident record review, and staff interview, the facility failed to ensure that there was a hospice agreement between the assisted living facility and any hospice program that provides care in the facility. Evidence: 1. Staff 3 provided a highlighted list containing the names of six (6) residents that are currently on hospice. 2. The LI requested the current hospice agreements. 3. In an interview with the LI, Staff 1 stated that hospice contracts were between the resident(s) and the hospice provider, not the facility.
Plan of Correction:	Executive Director and or designee will ensure that any hospice service provided in the community will have in place an agreement signed by the community and the hospice agency. The agreement will outlining the services provided by the hospice. The resident care plans will reflect acknowledgement of hospice services. All current residents who are on hospice care will have acknowledgement of hospice services on their care plan. All future residents placed on hospice will have acknowledgement of hospice service on their care plan. HWD will audit quarterly to ensure hospice acknowledgement is on ISP. Completed by 5/5/25
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) contained a description of identified needs based upon the uniform assessment instrument (UAI). Evidence: 1. Resident 1, admitted 12/02/2024, record contains a UAI dated 02/14/2025. The UAI states that the Resident 1 needs mechanical assistance for transferring, mechanical assistance/ human supervision for bathing, and mechanical assistance for toileting. Resident 1?s UAI states that Resident 1 needs mechanical assistance only for walking and mobility, and mechanical assistance with supervision for stairclimbing. 2. Resident 1?s ISP, dated 02/14/2025, does not include the mechanical assistance on bathing, toileting, and transferring. The ISP states that Resident 1 is independent for mobility/ambulation. 3. Resident 6?s UAI, dated 03/03/2025, states that Resident 6 needs mechanical assistance for toileting and mechanical assistance with supervision for bathing. 4. Resident 6?s ISP, dated 03/03/2025, does not include mechanical assistance for toileting or bathing. 5. In an interview with the LI on 03/20/2025, Staff 1 and 2 acknowledged that Resident 1 and Resident 6?s ISP does not contain a description of services from the UAI.
Plan of Correction:	450-C HWD will audit and ensure that all current residents ISP reflects the identified needs based upon the UAI. HWD will ensure that future UAI identified needs are reflected on ISP. Completed by 5/15/25
Standard #:	22VAC40-73-530-C
Description:	Based on direct observation, resident record review and staff interview, the facility failed to ensure that residents had freedom of movement between common areas and to their personal spaces. Evidence: 1. During a tour of the Safe, Secure Unit on 03/20/2025, the LI observed 10 locked rooms while the residents were eating breakfast. 2. In an interview with the LI, Staff 15 confirmed that all the resident doors remain locked when the residents are not in the room. Staff 15 stated that not all residents have a Fob (bracelet) to access the room. Staff 15 confirmed that residents are required to ask for access to their room. 3. In an interview with the LI, Staff 1 confirmed the doors on the Safe, Secure unit remain locked and select residents have Fob (bracelet) access to their rooms.
Plan of Correction:	Memory Care Director will ensure residents have freedom of movement in the common area and personal space. Residents who have been evaluated as able to unlock room doors will be given a fob for access. Memory Care Director will audit /assess quarterly to ensure continued ability of residents to access room on own with fob. All other resident rooms will be unlocked for resident accessibility to those who are unable to use a fob. Completed by 5/5/25
Standard #:	22VAC40-73-560-E
Description:	Based on direct observation and staff interview, the facility failed to ensure that all resident records were kept in a locked area. Evidence: 1. During a tour of the facility, the LI observed an unlocked office with the door open adjacent to the common area. Inside the office, a desk contained resident information. 2. In an interview with the LI, Staff 1 acknowledged that the door was open and unlocked. Staff 1 confirmed the office belonged to Staff 17. Staff 1 stated that Staff 17 provided services for the residents. 3. Photo evidence obtained.
Plan of Correction:	Executive Director and or designee will ensure staff keeps resident files and document in a secure cabinet, drawer or behind a locked door when staff not present. Executive Director and or designee will monitor throughout the day to ensure all staff are compliant with securing resident documents. Completed by 4/30/25
Standard #:	22VAC40-73-600-A
Description:	Based on direct observation, the facility failed to ensure that time between the evening and breakfast meals did not exceed 15 hours. Evidence: 1. During a tour of the facility on 03/20/2025, the LI observed Residents being sat for breakfast around 9:15 AM. 2. The scheduled mealtimes for the Safe, Secure Unit are 830-10 AM, 12 noon to 130 PM, 5pm to 630 PM. 3. In an interview with the LI, Staff 2 stated that dinner the prior evening (03/19/2025) was served around 5:15 PM. Staff 2 confirmed there were more than 15 hours between the dinner and breakfast meal.
Plan of Correction:	Memory care mealtimes adjusted to 8:30 12:30 and 5:30. Memory Care Director will monitor to ensure that mealtimes are adhered. Memory Care Director or designee will ensure residents are seated and served at designated times. Completed by 4/30/25
Standard #:	22VAC40-73-600-B
Description:	Based on direct observation and staff interview, the facility failed to ensure that there was at least four hours between breakfast and lunch meals. Evidence: 1. During a tour of the facility on 03/20/2025, the LI observed breakfast being served in the memory care unit at 9:30 AM. 2. The scheduled mealtimes for the Safe, Secure Unit are 830-10 AM, 12 noon to 130 PM, 5pm to 630 PM. 3. In an interview with the LI, Staff 2 stated that residents were sat for lunch around 12:00 PM and served around 12:30 PM. Staff 2 confirmed that there was less than 4 hours between breakfast and lunch.
Plan of Correction:	Memory Care mealtime adjusted to 8:30 12:30 and 5:30 Memory Care Director will monitor to ensure that mealtimes are adhered. Memory Care Director or designee will ensure residents are seated and served at designated times. Completed by 4/30/25
Standard #:	22VAC40-73-610-B
Description:	Based on direct observation and staff interview, the facility failed to ensure that menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents. Evidence: 1. During a tour of the dining area in the facility, the LI did not observe a posted menu. 2. In a meeting with the LI, Staff 1 confirmed that the weekly menu was posted in the dining area. 3. During a later observation of the dining area, the LI noted the weekly menu containing the breakfast, lunch, and dinner menu. The menu did not contain snacks. 4. In an interview with the LI, Staff 1 confirmed that the menu did not contain snacks. 5. Photo evidence obtained.
Plan of Correction:	Weekly menus will be dated and posted at the entrance to the dining room. Culinary Director and or designee will switch out menus before Sunday morning breakfast each week. Weekly menu will include snacks available. Culinary Director or Designee will monitor daily to ensure posting. Completed by 4/30/25
Standard #:	22VAC40-73-720-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that written Do Not Resuscitate (DNR) was included on the resident?s individualized service plan (ISP). Evidence: 1. Resident 1?s record contains a Durable DNR Order dated 11/29/2024. 2. Resident 1?s ISP, dated 02/14/2025, has a handwritten note at the top that says ?Do Not Intubate.? The DNR order is not on the ISP. 3. Resident 3?s record contains a Durable DNR Order dated 11/10/2022. 4. Resident 3?s ISP, dated 08/19/2024, does not include the DNR. 5. Resident 7?s record contains a Durable DNR Order dated 04/07/2023. 6. Resident 7?s ISP, dated 03/17/2025, does not include the DNR. 7. In an interview with the LI, Staff 1 and Staff 2 acknowledged that Resident 1, Resident 3, and Resident 7?s ISP did not contain a DNR.
Plan of Correction:	HWD will audit and ensure all current ISPs reflect the DNR status. HWD will ensure that future resident ISP reflects DNR status. HWD will audit quarterly to ensure all residnets with DNR have status reflected on ISP. Completed by 4/30/25
Standard #:	22VAC40-73-860-I
Description:	Based on direct observation and staff interview, the facility failed to ensure hazardous materials were stored in a locked area. Evidence: 1. During a tour of the facility, the LI observed an unlocked office with the door open adjacent to the common area that contained a fridge. Inside the fridge, a canister of chewing tobacco was sitting in the door. 2. In an interview with the LI, Staff 1 acknowledged that the door was unlocked. Staff 1 confirmed that the office began to Staff 17. Staff 1 stated that Staff 17 was hosting activities on a different floor at the time of observation. 3. Photo evidence obtained.
Plan of Correction:	Executive Director and/or designee will ensure all hazardous materials will remain in a locked area. Staff member inserviced?. keeping door, cabinet, and refrigerator area locked at all times when staff not present. Completed by 4/30/25
Standard #:	22VAC40-73-950-A
Description:	Based on facility document review and staff interview, the facility failed to ensure the local emergency coordinator was contacted. Evidence: 1. The LI requested a copy of the contact requesting required information from the local emergency coordinator. 2. In an interview with the LI, Staff 1 provided the corporate contact for the facility?s emergency management. 3. In an interview with the LI, Staff 16 confirmed that the local emergency coordinator had not been contacted.
Plan of Correction:	Maintenance Director reached out to Loudoun County and obtained the information for the local Emergency Coordinator for any updates that pertained to TOL. Information and contact was placed in the Emergency binder. .Maintenance Director will annually reach out to Emergency Coordinator for any updates and add to the Emergency binder. Completed
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment. Evidence: 1. Staff 5?s, hired 02/26/2025, Sworn Statement or Affirmation was signed and dated on 03/03/2025. 2. In an interview with the LI, Staff 1 confirmed that the Sworn Statements or Affirmations were completed after the hire date. 3. Staff 7?s, hired 07/05/2023, Sworn Statement or Affirmation was completed after employment began. 4. Staff 9?s, hired 06/05/2023, Sworn Statement of Affirmation was signed and not dated. 5. Staff 4?s, hired 06/05/2024, Sworn Statement or Affirmation was signed and not dated. 6. In an interview with the LI on 03/20/2025, Staff 10 could not confirm the dates for Staff 7, 9 or 4?s completion of the Sworn Statement or Affirmation.
Plan of Correction:	BOD will audit staff for compliance of Sworn Disclosure or Affirmation. Any missing Sworn Disclosures will be signed and date. Going forward BOD will ensure Sworn Disclosure is completed on or before hire date. BOD will audit staff records quarterly for compliance. Completed by 5/5/25
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that the criminal history record report was obtained for all employees on or prior to the 30th day of employment. Evidence: 1. Staff 7?s, hired 07/05/2023, Criminal Record Report was received 09/22/2023. 2. Staff 8?s, hired 10/18/2023, Criminal Record Report was received 11/21/2023. 3. In an interview with the LI on 03/20/2025, Staff 10 confirmed that the Criminal Record Reports were received after the 30th day of employment.
Plan of Correction:	Not available online. Contact Inspector for more information.