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: Aug. 5, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/08/2024 regarding allegations in the area(s) of resident care and related services and 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: 08/05/2024, 10:15 AM to 12:00 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0, resident refused interview at time of inspection. Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 #:	22VAC40-73-290-B
Complaint related:	No
Description:	Based on direct observation from the LI, the facility failed to ensure the current on-site person in charge was posted, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. At the front desk in the lobby, the manager on duty was listed as Staff 3. 2. Staff 4 confirmed that Staff 3 was not in the building or available, and that Staff 1 was the designated staff in charge.
Plan of Correction:	Designated person in charge will be listed at the front desk on the Designated Person in Charge tree. The Concierge will ensure the posting is located at the front desk every morning and visible to the public.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan included the following a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them. Evidence: 1. In a phone interview conducted by the LI on 08/05/2024, Staff 2 confirmed the following regarding the care of Resident 1: a. Resident 1 will talk loudly or yell due to hearing loss, which is sometimes deemed as aggressive when paired with her behaviors. b. Resident 1 has behaviors that are not triggered by certain staff. The behaviors include throwing items, refusal of care, and swatting or swinging at staff that attempt to provide care. Staff 2 has been providing on the job training and modeling of how to support this resident. Staff 2 stated they are on a ?try, try, and try again? plan of action with offering support with ADL?s, room cleaning, and eating breakfast. c. Resident 1 is currently undergoing psychiatric treatment to address concerns in behavior, and they have noticed that there is a decrease in behaviors once medication is leveled out. Staff 2 stated that they are continue to monitor and adjusting medications as needed. 2. Resident 1?s Uniform Assessment Instrument (UAI) lists the following under psychosocial: a. ?Behavior Pattern: Appropriate? b. ?Type of Inappropriate Behavior: Yelling, Smacking? 3. Resident 1?s ISP does not have a detailed description of needs or services provided. a. Under Neurocognitive, the description of service to be provided is ?Resident does not have hearing impairment.? b. Under Psychosocial, the description of service to be provided is ?Resident has current or history of frequent disruptive, aggressive, or socially inappropriate behavior, either verbally or physically improper. May require professional consultation or staff training.? 4. Staff 2 confirmed the system they use is does not give the ability to customize ISPs as much as necessary.
Plan of Correction:	Resident 1 UAI and ISP will be updated to reflect inappropriate behaviors and services provided. All residents UAI and ISP will be reviewed to ensure inappropriate behaviors are addressed, services to be provided and are customized as needed. Staff will receive continued training on methods and approaches to deal with inappropriate behaviors. RSD will review all UAI and ISPs on going to ensure compliance.