Inspection Reports for Tribute at One Loudoun by Cogir
20335 Savin Hill Dr, Ashburn, VA 20147, United States, VA, 20147
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Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Nov 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/30/2025 regarding allegations in the area of Resident Accommodations and Related Provisions.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The facility was observed to have a safe and secure unit.
Complaint Details
Complaint related to Resident Accommodations and Related Provisions; the complaint was not substantiated.
Report Facts
Number of residents present: 97
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: 1
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 1
Jul 28, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-27 regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, a violation unrelated to the complaint was identified concerning staff qualifications, specifically that a direct care staff member did not meet required qualifications at hire or within two months of employment.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2025-06-27 regarding allegations in Resident Care and Related Services and Resident Accommodations and Related Provisions. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that direct care staff met one of the requirements of the subsection at hire or within two months of employment. |
Report Facts
Number of residents present: 8
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Staff hire date: May 16, 2025
Plan of correction due date: Sep 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 3
Jul 28, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-04 regarding staffing and supervision, resident care and related services, and resident accommodations and related provisions.
Findings
The investigation supported the complaint of non-compliance with multiple standards, including insufficient staffing levels, delayed staff response to resident call bells, and failure to administer medications according to physician orders. Violations were issued and plans of correction were proposed.
Complaint Details
Complaint was substantiated with violations issued related to staffing, resident care, and medication administration. The complaint was received on 2025-07-04 and the inspection was complaint-related.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure sufficient staff numbers to provide services to maintain residents' physical, mental, and psychosocial well-being. |
| Facility failed to ensure care and service delivery was resident-centered and included prompt response by staff to resident needs. |
| Facility failed to ensure medications were administered in accordance with physician or prescriber orders. |
Report Facts
Number of residents present: 99
Number of shifts with insufficient staff: 30
Longest call bell response time (minutes): 238
Number of call bell instances over 20 minutes: 27
Number of call bell instances over 60 minutes: 9
Dates medication was administered against orders: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and interviews. |
| Wellness Director | Named as person responsible for plan of correction regarding staffing and medication administration. | |
| Executive Director | Named as person responsible for plan of correction regarding call bell response time. |
Inspection Report
Monitoring
Deficiencies: 1
Jun 2, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with administrative and administrative services standards, including options for plan of correction and license modification requests.
Findings
The inspection found non-compliance with applicable standards or laws, specifically the facility failed to maintain the minimum required liability insurance coverage. A violation notice was issued and the licensee has the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to have the minimum amount of liability insurance coverage required to be maintained by an assisted living facility. |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 3
Jun 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-05-02 regarding allegations in the area of Resident Accommodations and Related Provisions.
Findings
The investigation found multiple violations related to failure to update individualized service plans annually, improper medication administration not in accordance with physician orders, and failure to provide treatments as ordered. Violations were substantiated and corrective plans were submitted.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting non-compliance with standards and laws related to resident accommodations and medication administration.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) was updated at least once every 12 months. |
| Facility failed to ensure medications were administered in accordance with physician or prescriber orders. |
| Facility failed to ensure treatments ordered by a physician or prescriber were provided as ordered. |
Report Facts
Residents present: 111
Resident records reviewed: 1
Staff interviews conducted: 3
Blood sugar checks missed: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and interviews |
| Staff 1 | Interviewed staff member who acknowledged deficiencies and confirmed medication administration issues | |
| Health and Wellness Director | Person Responsible | Named as responsible for corrective actions and plans of correction |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
May 28, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-05-02 regarding allegations in administration, personnel, staffing, resident care, and accommodations.
Findings
The investigation supported the complaint of non-compliance with standards and violations were issued related to staff training on managing aggressive residents and medication storage security.
Complaint Details
The complaint was substantiated. Allegations involved administration, personnel, staffing, resident care, and accommodations. Violations were issued based on staff record reviews, interviews, and observations.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior prior to providing care. |
| Facility failed to ensure that the storage area for medication and dietary supplements was locked. |
Report Facts
Number of residents present: 110
Number of resident records reviewed: 8
Number of staff records reviewed: 2
Number of resident interviews conducted: 2
Number of staff interviews conducted: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff 1 | Acknowledged lack of training for Staff 5 and Staff 6 on aggressive resident care | |
| Staff 5 | Direct care staff without training in managing aggressive residents | |
| Staff 6 | Direct care staff without training in managing aggressive residents | |
| Staff 2 | Confirmed medication cart was unlocked |
Inspection Report
Monitoring
Census: 110
Deficiencies: 5
May 28, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-04-04 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance and violations were issued related to staff training, staffing plan maintenance, fall documentation, resident safety responsibility, and notification of legal representatives following resident falls.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure staff members received training on their duties and responsibilities prior to being placed in charge. |
| Facility failed to maintain a written staffing plan specifying the number and type of direct care staff. |
| Facility failed to ensure documentation of analysis of falls and interventions to prevent or reduce risk was completed when a resident falls. |
| Facility failed to assume general responsibility for the health, safety, and well-being of the resident. |
| Facility failed to ensure the legal representative was notified of any incident of a resident falling whether it results in injury. |
Report Facts
Number of residents present: 110
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of staff interviews conducted: 5
Inspection Report
Renewal
Deficiencies: 13
Mar 20, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including incomplete training documentation, lack of hospice agreements, incomplete individualized service plans, restricted resident freedom of movement, unsecured resident records, meal timing issues, missing meal menus and snacks, missing Do Not Resuscitate orders on service plans, improper storage of hazardous materials, failure to contact local emergency coordinator, incomplete sworn statements, and delayed criminal history reports.
Deficiencies (13)
| Description |
|---|
| Facility failed to ensure documentation of training included number of hours and was identifiable by individual staff member. |
| Facility failed to ensure hospice agreements were in place between the facility and hospice providers. |
| Individualized service plans did not reflect identified needs based on uniform assessment instruments. |
| Residents did not have freedom of movement between common areas and personal spaces due to locked doors. |
| Resident records were not kept in a locked area. |
| Time between evening and breakfast meals exceeded 15 hours. |
| Less than four hours between breakfast and lunch meals. |
| Menus for meals and snacks were not dated or posted conspicuously and did not include snacks. |
| Written Do Not Resuscitate orders were not included on residents' individualized service plans. |
| Hazardous materials were not stored in a locked area. |
| Local emergency coordinator was not contacted as required. |
| Sworn statements or affirmations were not completed for all applicants prior to or on hire date. |
| Criminal history record reports were not obtained for all employees on or prior to the 30th day of employment. |
Report Facts
Number of resident records reviewed: 8
Number of staff records reviewed: 6
Number of residents on hospice: 6
Number of locked rooms observed: 10
Time between dinner and breakfast meals: 15
Number of staff with delayed criminal record reports: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection |
| Staff 1 | Interviewed regarding hospice agreements, locked doors, resident records, meal times, menus, DNR orders, hazardous materials, emergency coordinator, sworn statements | |
| Staff 2 | Interviewed regarding meal times | |
| Staff 3 | Interviewed regarding training documentation and hospice agreements | |
| Staff 15 | Interviewed regarding locked doors on Safe, Secure Unit | |
| Staff 16 | Interviewed regarding local emergency coordinator contact | |
| Staff 17 | Responsible for office where resident records and hazardous materials were found unsecured | |
| Staff 10 | Interviewed regarding sworn statements and criminal record reports |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 3
Feb 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-01-28 regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The investigation supported some, but not all, of the allegations, identifying non-compliance in Resident Care and Related Services. Violations were found related to failure to report major incidents within 24 hours, failure to complete the Uniform Assessment Instrument annually, and failure to immediately report suspected abuse or neglect.
Complaint Details
The complaint investigation was substantiated in part, with violations found in Resident Care and Related Services. The evidence included resident record reviews, staff interviews, and collateral contacts. Some allegations were not supported.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that any major incident negatively affecting a resident is reported to the regional licensing office within 24 hours. |
| Facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed annually. |
| Facility failed to ensure matters giving reason to suspect abuse, neglect, or exploitation of adults were reported immediately upon determination. |
Report Facts
Number of residents present: 105
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and interviews |
| Staff 1 | Named in findings related to failure to report incidents and abuse | |
| Staff 2 | Interviewed regarding Uniform Assessment Instrument completion |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 2
Jan 30, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-01-08 regarding allegations related to personnel, staffing, and supervision at the facility.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in staffing and supervision standards, including failure to maintain a written staffing plan specifying direct care staff needs and failure to ensure prompt response to care as determined by circumstance.
Complaint Details
The complaint was substantiated in part, with non-compliance found in staffing and supervision. Evidence included staff interviews, resident interviews, document reviews, and call bell response records showing delays and insufficient staffing.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a written staffing plan specifying the number and type of direct care staff required to meet routine and special needs. |
| Facility failed to ensure prompt response to care as determined by circumstance, including delayed call bell response times. |
Report Facts
Number of residents present: 106
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 4
Call bell responses over 15 minutes: 15
Call bell response delays: 60
Staffing minimums per shift: 4
Staffing minimums per shift: 2
Staffing minimums per shift: 2
Staffing minimums per shift: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff 1 | Interviewed regarding staffing plan and call bell response policies | |
| Staff 2 | Interviewed regarding call bell system and response times | |
| Staff 3 | Interviewed regarding staffing levels and resident complaints about wait times | |
| Staff 4 | Interviewed regarding staffing levels and resident complaints about wait times | |
| Staff 5 | Interviewed regarding call bell response times | |
| Resident 1 | Interviewed regarding delays in care and call bell response times | |
| Resident 3 | Participated in resident council discussion about staffing shortages |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 7
Jan 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2024-12-15 regarding allegations in the areas of Admission, Retention, and Discharge of Residents; Resident Care and Related Services; and Resident Accommodations and Related Provisions.
Findings
The investigation supported some, but not all, of the allegations. Multiple violations were found related to admission procedures, incident reporting, medication management, and care planning, including failure to retain required documentation, failure to report incidents timely, and failure to administer medications as ordered.
Complaint Details
The complaint was substantiated in part; some allegations were supported by evidence including failures in admission documentation, incident reporting, care planning, and medication administration.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure written acknowledgement of receipt of disclosure by resident or legal representative was retained in the resident's record. |
| Facility failed to ensure a report was sent to the regional licensing office within 24 hours for any major incident affecting resident safety. |
| Facility failed to ensure determination was made that it could meet the needs of the individual based on physical examination prior to admission. |
| Facility failed to ensure a preliminary plan of care was developed and signed by the resident or legal representative within seven days prior to admission. |
| Facility failed to ensure physician's notes and progress reports were retained in the resident's record. |
| Facility failed to ensure its medication management plan was implemented. |
| Facility failed to ensure medications were administered according to physician or prescriber orders. |
Report Facts
Number of residents present: 107
Number of resident records reviewed: 1
Number of staff interviews conducted: 5
Medication administration dates missed: 4
Plan of care completion timing: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and interviews |
| Staff 1 | Acknowledged missing disclosure form, incident report not written, and medication errors | |
| Staff 3 | Completed admission assessment and confirmed psychiatric services | |
| Staff 4 | Reported incident involving Resident 1 and sheriff arrival | |
| Staff 2 | Acknowledged medication orders included but not administered |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
Jan 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-07 regarding allegations in the areas of Administration and Administrative Services, Staffing and Supervision, and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in Administration and Administrative Services, specifically related to failure to fully implement the developed infection control program during a gastrointestinal outbreak.
Complaint Details
The complaint was substantiated in part; evidence showed failure to fully implement infection control measures during a gastrointestinal outbreak, including lack of documentation and incomplete adherence to the infection control policy.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the developed infection control program was implemented, including not canceling all group activities and not closing dining services during a gastrointestinal outbreak as required by policy. |
Report Facts
Number of residents present: 107
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 102
Deficiencies: 0
Dec 5, 2024
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 10/19/2024 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection included a tour of the physical plant and interviews with staff.
Report Facts
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: 4
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 5, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-06-08 regarding allegations related to resident care and related services and resident accommodations.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, including failure to post the current on-site person in charge conspicuously and failure to ensure the individualized service plan included a comprehensive written description of services to address identified needs.
Complaint Details
Complaint related to resident care and related services and resident accommodations was investigated and found not substantiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the current on-site person in charge was posted in a conspicuous place to residents and the public. |
| Facility failed to ensure the comprehensive individualized service plan included a written description of services to address identified needs and who will provide them. |
Report Facts
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: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 31, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-08-04 regarding allegations in the areas of administration and administrative services and admission, retention, and discharge of residents.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings, and the inspection summary will be posted publicly.
Complaint Details
Complaint investigation related to allegations in administration and administrative services and admission, retention, and discharge of residents; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 15
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Mar 30, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-03-21 regarding allegations in the area of resident care.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
A complaint was received on 2023-03-21 regarding resident care. The investigation found no substantiated non-compliance.
Report Facts
Number of residents present: 100
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: 2
Inspection Report
Renewal
Census: 96
Deficiencies: 3
Feb 7, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with licensing requirements prior to the expiration of the current license.
Findings
The inspection identified non-compliance with applicable standards and laws, resulting in documented violations related to staff first aid certification, inclusion of Do Not Resuscitate orders in care plans, and pet immunization records.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification within 60 days of employment. |
| Facility failed to ensure that the written order for Do Not Resuscitate (DNR) is included in the Individualized Service Plan (ISP). |
| Facility failed to ensure that pets living on the premises have regular examinations and immunizations by a licensed veterinarian; specifically, Pet #3 lacked documentation of an updated rabies vaccination. |
Report Facts
Number of residents present: 96
Number of resident records reviewed: 12
Number of staff records reviewed: 5
Number of interviews with residents: 0
Number of interviews with staff: 0
Inspection Report
Monitoring
Deficiencies: 0
Nov 1, 2022
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 10/24/2022 regarding allegations in the areas of admission, retention, discharge of residents, and resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were cited.
Report Facts
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: 1
Inspection Report
Monitoring
Deficiencies: 0
Mar 22, 2022
Visit Reason
Unannounced focused monitoring visit to ensure correction of violations cited during the 2/4/2022 renewal study.
Findings
All previous violations were found to have been corrected. No additional violations were cited during this visit.
Inspection Report
Census: 6
Deficiencies: 1
Feb 9, 2022
Visit Reason
The inspection was conducted in response to self-reported incidents involving a resident injury during van transport that began on 2/9/2022 and concluded on 3/25/2022.
Findings
The facility failed to provide adequate care to protect the health, safety, and well-being of residents, specifically related to an incident where a resident fell out of a van due to an improperly latched door and unsecured wheelchair, resulting in serious injuries.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide adequate care to protect the health, safety, and well-being of residents during transportation, resulting in a resident falling out of a van and sustaining injuries. |
Report Facts
Residents on van during incident: 6
Injuries to resident: 4
Staples required: 4
Inspection Report
Monitoring
Deficiencies: 0
Feb 2, 2022
Visit Reason
Unannounced focused monitoring visit to ensure correction of violations cited during previous complaint inspections on 10/4/2021 and 12/13/2021.
Findings
All previous violations were found to have been corrected. No additional violations were cited during this visit.
Inspection Report
Renewal
Census: 90
Deficiencies: 4
Feb 1, 2022
Visit Reason
An unannounced renewal study was conducted from February 1 to February 4, 2022, to assess compliance with licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations related to medication management, including failure to ensure timely medication refills, late administration of medications, missed doses due to staffing issues, and incomplete individualized service plans for residents unable to use signaling devices.
Deficiencies (4)
| Description |
|---|
| Failed to ensure that the written medication management plan was implemented to ensure timely medication refills, resulting in missed doses for residents. |
| Failed to ensure medications were administered within one hour before or after the scheduled dosing times, resulting in late medication administration. |
| Failed to ensure medications were administered according to physician's instructions, resulting in missed doses due to staffing challenges. |
| Failed to include in the individualized service plan the inability of a resident to use the signaling device and the required frequency of staff rounds. |
Report Facts
Residents in care at time of inspection: 90
Resident records reviewed: 10
Staff records reviewed: 5
Pet records reviewed: 6
Medication administration late occurrences: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Inspector | Named as current inspector conducting the inspection |
| Resident Services Director | Resident Services Director (RSD) | Responsible for medication audits and staff re-education as part of plan of correction |
| Memory Care Director | Memory Care Director (MCD) | Interviewed regarding resident's inability to use call bell system and responsible for updating individualized service plans |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 4, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received regarding allegations in the areas of resident care at the assisted living facility.
Findings
The investigation found that the facility failed to follow its fall response procedures and did not ensure residents' rights and responsibilities as required by law. Violations were issued related to inadequate response to a resident's fall and failure to offer hospital transfer despite reported pain and injury.
Complaint Details
The complaint investigation was substantiated with evidence supporting allegations of non-compliance with standards and law related to resident care and fall response procedures.
Deficiencies (2)
| Description |
|---|
| Facility failed to follow fall response procedures after a resident sustained a fall and hit his head, including not calling 911 when required. |
| Facility failed to ensure residents' rights and responsibilities as provided in the Code of Virginia, including the right to participate in care planning and refuse treatment. |
Report Facts
Inspection dates: 2
Pain level reported: 8
Time to surgery: 12
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 18, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the area of resident care. The investigation was conducted through review of documentation and communication with the administrator.
Findings
The investigation found non-compliance with standards related to failure to complete a Uniform Assessment Instrument (UAI) upon significant change in resident condition, failure to update individualized service plans as needed, and failure to provide necessary personal assistance including dressing. Multiple incidents involving Resident #1's disruptive and inappropriate behaviors were documented.
Complaint Details
The visit was complaint-related based on a self-reported incident regarding resident care. The evidence supported the self-report of non-compliance with standards or law, and violations were issued.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that a UAI shall be completed whenever there is a significant change in the resident's condition. |
| Facility failed to ensure that individualized service plans shall be reviewed and updated as needed as the condition of the resident changes. |
| Facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with dressing. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received regarding allegations in the areas of resident care.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with the standards or law.
Complaint Details
Complaint related visit; the complaint was investigated and found to be unsubstantiated.
Inspection Report
Monitoring
Deficiencies: 0
Mar 18, 2021
Visit Reason
A focused monitoring inspection was initiated on 3/18/2021 and concluded on 3/31/2021 to ensure correction of violations cited during 1/26/2021 and 2/25/2021 complaint inspections.
Findings
All previous violations were found to have been corrected. The inspection determined no violations with applicable standards or law, and no new violations were issued.
Report Facts
Resident records reviewed: 10
Inspection Report
Renewal
Census: 73
Deficiencies: 0
Mar 15, 2021
Visit Reason
A renewal inspection was initiated on March 15, 2021 and concluded on March 19, 2021 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations with applicable standards or law. No deficiencies were issued during the inspection.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 7
Jan 26, 2021
Visit Reason
A complaint inspection was initiated on 2021-01-25 and concluded on 2021-02-25 due to allegations regarding staffing quantity, medication administration, and resident care at Tribute at One Loudoun assisted living facility.
Findings
The investigation found multiple violations including insufficient staffing to meet resident needs, delayed medication administration, failure to respond promptly to resident needs, medication administration errors, incomplete documentation of medication administration, and failure to follow physician orders for treatments and procedures. These deficiencies were linked to a COVID-19 outbreak affecting 49 residents and staff.
Complaint Details
The complaint was substantiated with evidence supporting allegations of non-compliance in staffing, medication administration, and resident care. Violations were issued based on findings.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure sufficient staff numbers to provide services to maintain residents' well-being as determined by assessments and service plans. |
| Facility failed to provide prompt response by staff to resident needs as reasonable to the circumstances. |
| Medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. |
| Medications were not administered in accordance with physician's or prescriber's instructions and standards of practice. |
| Medical procedures or treatments ordered by a physician were not provided according to instructions. |
| Medication administration records did not document all medications administered at the time of administration. |
| Medication administration records did not include initials of direct care staff administering medications. |
Report Facts
Residents affected by COVID-19 outbreak: 49
Inspection dates: Inspection conducted from 2021-01-26 to 2021-02-25.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 14, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding staff quantity and infection control procedures at the facility.
Findings
The investigation reviewed resident records, staff schedules, response times, and infection control policies, and concluded that the evidence did not support the allegations of non-compliance. The complaint was deemed not valid.
Complaint Details
Complaint related to staffing quantity and infection control; complaint was not substantiated as evidence did not support the allegations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the complaint investigation and communicated with the administrator. |
Inspection Report
Monitoring
Deficiencies: 2
Dec 14, 2020
Visit Reason
A focused monitoring inspection was initiated due to a self-reported incident regarding allegations in the areas of resident care. The inspection was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation found non-compliance with standards related to medication administration, including failure to have valid physician orders for medication discontinuation and administration of medication outside prescribed instructions. Violations were issued and plans of correction were required.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued without a valid order from a physician or other prescriber. |
| Facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions and consistent with standards of practice. |
Report Facts
Medication doses administered: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Inspector | Named as the current inspector conducting the inspection. |
| Resident Services Director | RSD | Responsible for re-educating staff and implementing corrective actions related to medication administration violations. |
Inspection Report
Monitoring
Deficiencies: 4
Nov 20, 2020
Visit Reason
A focused monitoring inspection was initiated due to a self-reported incident regarding allegations in the areas of resident care. The inspection was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation supported the self-report of non-compliance with standards or law related to medication administration, documentation, and handling. Multiple violations were cited regarding failure to keep medications in pharmacy containers, failure to administer medications as prescribed, and incomplete medication administration records.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure medications remained in the pharmacy issued container with prescription label until administered. |
| Facility failed to ensure medications were administered in accordance with prescriber's instructions. |
| Facility failed to document all medications administered on the Medication Administration Record (MAR), including over-the-counter medications and dietary supplements. |
| Facility failed to ensure the MAR included symptoms for which 'as needed' medications were given, exact dosage, and effectiveness. |
Report Facts
Inspection dates: Inspection conducted from 2020-11-20 to 2020-12-02
Medications scheduled: 6
Medication doses missed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Inspector | Current inspector conducting the inspection |
| Paul | Resident involved in medication administration deficiencies | |
| Staff #1 | Staff member involved in medication administration errors and provided written statements | |
| Resident Services Director | Person responsible for re-educating medication aides as part of plan of correction |
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