Tribute at One Loudoun
Families consistently rate this highly — reviewers highlight beautiful, modern, and clean community. Schedule a visit to confirm the fit.
based on 55 Google reviews
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What this means for your family
This facility offers a beautiful, high-end environment and a very caring frontline nursing staff. However, families should exercise extreme caution regarding administrative oversight and medication management, as recent reviews indicate significant lapses in leadership and safety protocols.
Google Reviews
Google Reviews
55 reviews on Google“Tribute at One Loudoun is widely praised for its beautiful, modern, and resort-like facility that provides a high quality of life for many residents. While many families report exceptional, compassionate care from the nursing and frontline staff, there are serious documented concerns regarding administrative leadership, medication management errors, and inconsistent meal quality.”
Quality Themes
Tap a score for detailsStrengths
- Beautiful, modern, and clean community
- Compassionate and attentive frontline staff
- Convenient location near hospitals and amenities
- Engaging resident activities and social programs
Concerns
- Administrative and leadership failures (mentioned by 2 reviewers)
- Inconsistent meal quality and portion sizes (mentioned by 2 reviewers)
- Medication management negligence
Rating Trends
Tap a year to see what changed
Distribution · 31 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1It is wonderful to see how much care you put into responding to community feedback; how does the leadership team use resident and family input to improve daily operations?
- 2The dining area looks beautiful; could you tell us more about how the menu is planned and how you ensure consistent meal quality and portion sizes for every resident?
- 3With the modern amenities here, what are some of the most popular social programs or daily activities that keep residents engaged?
- 4Could you walk us through your specific protocols for medication management to ensure everything is handled with complete accuracy?
- 5Since you are memory care certified, how do your staff members specifically adapt their care approach for residents with different stages of cognitive decline?
- 6In the event of a medical emergency after hours, what is the specific process for coordinating care between the facility and the nearby hospitals?
Personalized based on this facility's data
Key Review Excerpts
“My mother spent her last year at Tribute. She would want to thank the staff there for all the support they gave her during her final year. Her quality of life improved markedly after her move from an independent living facility.”
“The most unprofessional, negligent group of individuals I have ever encountered. I don't know where to even begin, the lack of professionalism, the fact that our loved one missed almost a week's worth of important medications due to their negligence”
“Tribute at One Loudoun is a modern resort like community, very clean and efficient! Highly recommend to families/seniors looking to enjoy a resort lifestyle everyday!”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Mar 11, 2026Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2026 2:00 PM to 3:25 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 02/11/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions 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: 3 Observations by licensing inspector: Record review. 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 self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 ?AJ? Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Based on resident record review and staff interview, the facility failed to ensure that the UAI
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan ( ISP
Based on resident record review and staff interview, the facility failed to ensure that physician or other prescriber?s orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services were recorded in the resident?s record. Evidence: 1. On 02/18/2026, the facility submitted a self-reported incident regarding a bruise on the right eye of Resident 1. The report states that the right eye was traced back to Resident 1 being found by a caregiver with Resident 1?s head, shoulder, and arm through the enabler bar on Resident 1?s bed. 2. During a record review and interview with two LI?s on 03/11/2026, Staff 1 confirmed that Resident 1?s enabler bar, used for transferring assistance, was not documented in Resident 1?s record. 3. During the preliminary exit meeting held on site with two licensing staff on 03/11/2026, Staff 1, Staff 2, and Staff 3 acknowledged that physician or other prescriber?s orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services were not recorded in the resident?s record.
Mar 11, 2026Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2026 12:30 PM to 2:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 02/25/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions 2. Staffing and Supervision 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident and Staff Records Additional Comments/Discussion: Both resident and staff involved in self-reported incident were not available at the facility at the time of inspection. Pre-liminary (on-site) exit meeting was conducted with staff both in person and on the phone. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 ?AJ? Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Based on staff record review and staff interview, the facility failed to ensure that all staff who are mandated reporters reported suspected abuse, neglect, or exploitation of residents. Evidence: 1. During an on-site review of staff records, it was observed that Staff 2?s record contained multiple written statements from other staff members that detailed Staff 2 refusing and/or not completing resident care tasks for multiple residents including Resident 2, Resident 3, and Resident 4 between October of 2025 and December of 2025. 2. During the preliminary exit meeting held on site with two licensing staff on 03/11/2026, Staff 1, Staff 2, and Staff 3 acknowledged that a report was not completed for the alleged neglect by Resident 1.
Based on staff record review, the facility failed to ensure that personal assistance and care were provided to each resident as necessary so that the needs of the resident are met, including assistance or care with activities such as bathing, toileting, and housekeeping. Evidence: 1. On 02/25/2026, Staff 3 reported that Resident 1 alleged that Staff 2 smacked Resident 1 on the bottom while providing incontinent care at the end of November 2025 or beginning of December 2025. 2. Resident 1 was on respite at the facility from 11/29/2025 to the week of 02/24/2026. 3. Staff 2 was employed from 01/06/2025 to 12/21/2025. 4. Staff 2?s record, provided on site by Staff 1, contained multiple written statements from other staff members that detailed Staff 2 refusing and/or not completing resident care tasks. The written statements are summarized as follows: a. A typed document signed ?Night Shift? stated that there were ongoing issues when Staff 2 was in the building. These issues, including resident trash cans not being emptied, residents being left wet, residents not having their clothing changed, and residents being left on top of their blankets. The note contained an illegible signature and was dated 11/14/2025. b. A handwritten document signed and dated by Staff 5 on 11/14/2025 that stated that Staff 2 was leaving trash in the hallway and elevator area, and that Staff 2 was not checking on or toileting residents despite requests to do so. c. A handwritten note signed and dated by Staff 6 on 12/03/2026 that stated that both Resident 2 and Resident 3 had scheduled morning showers that had not been completed, and both Resident 2 and Resident 3 were upset. Staff 6 stated that Staff 6 was asked to provide care by Staff 7, and that Resident 3?s shower was completed later that evening. d. A typed email between Staff 7 and Staff 1 on 12/08/2026 details additional concerns reported on 12/03/2026. Staff 7?s email states that Resident 2 and Resident 3 were assigned to Staff 2. The email states that Resident 2 was found on 12/03/2026 in the same clothes as the day before, with no under garments. The email states that when the shower was given to Resident 2, Staff 6 observed overflowing trash and breakfast/lunch trays not removed from the apartment. The email states that upon arrival to Resident 3?s room, Resident 3 was soiled and needed a shower. e. A written statement dated 12/10/2025 by Staff 1 confirms that multiple reports from other team members and residents were received regarding Staff 2 not emptying the trash, not appropriately dressing residents, not answering resident call pendants and having an attitude with both staff and residents when asked to provide care. 5. Corrective Action Notices for Staff 2 regarding incompletion of tasks on 12/08/2025 (updated on 12/10/2025), 11/26/2025, and 10/21/2025 were located within Staff 2?s provided record.
Mar 11, 2026Complaint
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2026 9:30 AM to 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/25/2026 regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Resident Accommodations and Related Provisions 3. Additional Requirements for Facility that Care for Adults with Serious Cognitive Impairment 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: 0 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 7 Observations by licensing inspector: Resident Activities in the Safe, Secure Unit Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 ?AJ? Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Based on direct observation and staff interview, the facility failed to ensure minimum awake and on duty direct care staffing in the special care unit as required based on resident census. Evidence: 1. On 03/11/2026, Staff 4 confirmed the census in the safe, secure unit as 29. 2. The schedule and time clock indicate there were three direct care staff members, along with one registered medication aide. Staff 13 was clocked out for break from 11:01 AM to 11:31 AM. 3. On 03/11/2025, two LI?s were in the safe, secure unit at the facility. The LI?s observed Staff 8 in the activity room with 20 residents (two of which were in the adjacent dining area) until approximately 11:05 when Staff 9 arrived. When staff 9 arrived, Staff 8 left the area. The LI?s walked up and down the hallway, attempting to locate another staff member. Another care staff member was not seen until approximately 11:30 when Staff 10 arrived and was in the dining area with Staff 2. 4. After leaving the safe, secure unit around 11:30 AM, two LI?s observed Staff 9 in the lobby area on the first floor, outside of the safe, secure unit. 5. In an interview with two LI?s on 03/11/2026, Staff 2 stated there were typically three staff assisting and Staff 2 was unsure where they were at the time of inspection.
Based on resident record review and staff interview, the facility failed to ensure that there was a designated person responsible for managing or coordinating the structured activities program in the safe, secure unit. Evidence: 1. Staff 11, the designated activities person, resigned on 01/09/2026. 2. Staff 1, the current designated activities person, began employment on 02/02/2026, per the staff record. 3. Per interviews with Staff 2, Staff 3, and Staff 1, there was not a qualified designated activities person from 01/09/2026 to 02/02/2026.
Based on direct observation and staff interview, the facility failed to ensure that the staff outside of the administrator and direct care staff completed two hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care. Evidence: 1. Staff 1 was hired on 02/02/2026 to the activities deoparrtment. Staff 1?s record did not contain two hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care within the first month of employment. 2. Staff 3 was originally hired on 01/29/2025 as a server but transferred to activities on 08/26/2025. Staff 2?s record contained training titled Dementia Training dated 02/05/2026; however, the number of hours was not listed. 3. During the onsite preliminary exit meeting with two LI?s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that Staff 1?s training had not been completed during the first month of hire, and that Staff 3?s training hours were not listed and able to document that two hours were received within the first month of employment.
Based on direct observation, staff record review, and staff interview, the facility failed to ensure that the staff person or volunteer leading the activity had a general understanding of the following: attention spans and functional levels of the residents; methods to adapt the activity to meet the needs and abilities of residents, various methods of engaging and motivating residents to participate, and the importance of providing appropriate instruction, education, and guidance throughout the activity. Evidence: 1. On 03/11/2026 from approximately 11:00 AM to 11:30 AM, two LI?s observed activities in the safe, secure unit at the facility. Upon the arrival, 18 residents were located in the activity room playing a version of Hangman with Staff 2, while two (2) residents were located in the adjacent dining area, across the hallway with no line of sight to the activity being conducted. During the activity, one to two participants were seen actively participating, while approximately eight residents were sleeping during the activity. At one point, Staff 2 called on a resident that was observed sleeping, and when there was no response stated out loud ?Still sleeping?? before laughing and continuing the game. 2. Around 11:05 AM, a contract musician began to play music with a guitar. There was no transition or introduction to the activity, and simultaneously, no expectations given to residents. The musician apologized for the loud music, stating that the residents needed to wake up. 3. In a follow-up email with Staff 2 on 03/11/2026, two LI?s asked specific questions related to the four topics listed above. Staff 2 stated their previous experience included various customer service positions, outside of the senior living population. 4. Staff 2?s training record was reviewed. Of 23 hours of training, Staff 2?s record contained 1 hour of activity-specific training from September of 2025. 5. In an interview with Staff 3, another activity staff member that shares a position with Staff 2, Staff 3 was asked the same questions. Staff 3 stated they had previous volunteer experience from school, and while they had limited training, it?s important to try things out to see if they work. If it doesn?t work, Staff 3 will research other solutions online. 6. Staff 3?s training record was reviewed and contained 3.2 hours of training for the last year of employment, none of which were related to activities. 7. During the onsite preliminary exit meeting with two LI?s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that Staff 2 and Staff 3 do not have a general understanding of understanding of attention spans and functional levels of the residents; methods to adapt the activity to meet the needs and abilities of residents, various methods of engaging and motivating residents to participate, and the importance of providing appropriate instruction, education, and guidance throughout the activity.
Based on direct observation, document review, and staff interview, the facility failed to ensure there was a written schedule of activities that included changes noted on the schedule. Evidence: 1. On 03/11/2026, the LI observed the posted activities to include 10:00 AM ? Words in a Word and 11:00 AM ? Chair Volleyball. On 03/11/2026, the LI observed the unit playing Hangman at 10:55 AM and a musician began playing at 11:05 AM. 2. In an interview with two LI?s on 03/11/2026, both Staff 1 and Staff 2 confirmed that the schedule had not been updated to reflect changes in programming. 3. During the onsite preliminary exit meeting with two LI?s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that the written schedule of activities had not been updated.
Based on direct observation and staff interview, the facility failed to ensure the buildings and grounds were maintained in good repair. Evidence: 1. During an onsite tour of the facility on 03/11/2026, two LI?s observed multiple areas of the floorboards peeling with what appeared to be water damage on the 2nd floor, safe, secure unit. In some areas, the paint leading up the corners from the floorboard was also peeling. 2. In an interview with two LI?s on 03/11/2026, Staff 7 confirmed that the material on the floorboards was damaged due to the liquid used when needing to clean carpets. 3. During the onsite preliminary exit meeting with two LI?s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that the building was not in good repair. 4. Photo evidence obtained.
Based on direct observation and staff interview, the facility failed to ensure that the building was free of foul and musty odors. Evidence: 1. During an onsite tour of the facility on 03/11/2026, two LI?s observed a foul odor on the memory care unit hallway directly to the right of the hallway. 2. During the onsite preliminary exit meeting with two LI?s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that the facility had a foul odor on the memory care hallway.
Feb 4, 2026Routine10Report
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/04/2026 10:35 AM to 3:45 PM 02/05/2026 9:15 AM to 3:55 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: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 4 Number of interviews conducted with residents: 7 Number of interviews conducted with staff: 4 Observations by licensing inspector: Meals, Activities, and Medication Pass Additional Comments/Discussion: Please submit renewal application prior to expiration. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 ?AJ? Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Based on resident record review and staff interview, the facility failed to ensure a disclosure statement, on the form developed by the department, was prepared and provided to the prospective resident and prospective resident's legal representative. Evidence: 1. Resident 8?s (Admitted 12/17/2025) record contained a disclosure statement not on the approved form developed by the department. 2. In an interview with the LI on 02/05/2026, Staff 1 confirmed that the disclosure form was not on the form developed by the department.
Based on staff record review and staff interview, the facility failed to ensure direct care staff met one of the requirements upon hire or within two months of employment. Evidence: 1. Staff 3 was hired on 01/20/2025 as a direct care staff member. Staff 3?s record did not contain documentation of the required qualifications upon hire or within two months of employment. 2. Staff 5 was hired on 10/31/2025 as a direct care staff member. Staff 5?s record did not contain documentation of the required qualifications upon hire or within two months of employment. 3. In an interview with the LI on 02/04/2026, Staff 1 confirmed that Staff 3 and Staff 5 did not have the required qualifications upon hire or within two months of employment.
Based on staff record review and staff interview, the facility failed to ensure all direct care staff attended at least 18 hours of training annually. Evidence: 1. Staff 6 was hired on 01/20/2025 as a direct care staff member. Staff 6?s record contained 8.75 hours of the required annul training. 2. In an interview with the LI on 02/04/2026, Staff 1 confirmed that Staff 6 did not have the required 18 hours of training annually.
Based on staff record review and staff interview, the facility failed to ensure current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department was maintained for each staff member. Evidence: 1. Staff 3 (Hired 01/06/2025), Staff 4 (Hired 10/31/2025), and Staff 5?s (Hired 11/17/2025) records did not contain current certification in first aid. 2. In an interview with the LI on 02/04/2026, Staff 1 confirmed that Staff 3, Staff 4, and Staff 5 did not have current certification in first aid.
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan ( ISP
Based on resident record review and staff interview, the facility failed to ensure physician or other prescriber orders included the name of the resident, date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or indication for administration. Evidence: 1. Resident 2?s record contained orders for the following three medications that do not include a diagnosis, condition, or indication for administration. a. Torsemide 20 MG Tablet: Take 1 tablet by mouth daily b. Lasix 40 MG Tablet: Take 1 tablet by mouth once daily. c. Mirtrazapine 15 MG: Take 1 tablet by mouth once at bedtime 2. In an interview with the LI on 02/05/2026, Staff 1 confirmed that the orders did not contain the diagnosis, condition, or indication for administration.
Based on resident record review and staff interview, the facility failed to ensure medication was administered in accordance with the physician or other prescribers? instructions and consistent with the standards of practice approved by the Virginia Board of Nursing. Evidence: 1. Resident 7?s record contains an order for Amlodipine Tab 2.5MG with parameters. The order reads ?Take 1 tablet by mouth once daily for high blood pressure **Hold for SBP less than 120 and/or DBP less than 70**.? 2. Resident 7?s Medication Administration Record ( MAR
Based on resident record review and staff interview, the facility failed to ensure the medication administration record ( MAR
Based on resident record review and staff interview, the facility failed to ensure a valid written order has been issued by the resident's attending physician and the written order is included in the individualized service plan ( ISP
Based on direct observation and staff interview, the facility failed to ensure grounds were properly maintained to include mowing of grass and removal of snow or ice. Evidence: 1. On 02/04/2026, the LI observed both the front patio area off the bistro and the memory care patio (2nd floor) off of the kitchen to be covered in snow and ice. 2. Photo evidence obtained. 3. In an interview with the LI on 02/04/2026, Staff 7 confirmed that the snow and ice had not been properly removed from the grounds.
Nov 13, 2025ComplaintCleanReport
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 10/30/2025 regarding allegations in the area(s) of: 1. 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: 11/13/2025 12:30 PM to 2:00 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: 97 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: 1 Observations by licensing inspector: Safe, Secure Unit. Additional Comments/Discussion: Staff member mentioned in complaints could not be identified. 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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
Nov 13, 2025Routine
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/28/2025 regarding allegations in the area(s) of: 1. 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: 11/13/2025 9:30 AM to 12:30 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: 97 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Safe, Secure Unit. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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
Based on resident record review and staff interview, the facility failed to ensure compliance with the facility?s own policies and procedures. Evidence: 1. On 10/28/2025, the facility reported injuries of unknown origin sustained by Resident 1 on 10/27/2025. 2. After reviewing statements from Staff 2 and Staff 3, it was determined that Staff 2 noticed the injury around lunchtime, while Staff 3 noticed the injury around 4PM. Staff 3?s statement indicated that the day shift, including Staff 2, did not notice any observations. 3. The facility?s ?Change in Condition? policy states that staff will report any observations that indicate a possible change of condition the WD or ED. 4. A timeline of the incident was provided by Staff 1. The timeline stated that Staff 2 failed to report a change in condition. 5. In an interview with two LI?s, Staff 1 confirmed that Staff 2 did not report a change in condition, according to the facility?s own policy.
Based on resident record review and staff interview, the facility failed to ensure supervision of specialized needs such as prevention of falls. Evidence: 1. On 10/28/2025, the facility reported injuries of unknown origin sustained by Resident 1 on 10/27/2025. 2. Resident 1?s record contained an after-visit summary, dated 10/29/2025, stated the reason for the visit was ?fall? and ?head injury? with a diagnosis of fall, facial hematoma, severe dementia, renal insufficiency, and hyperglycemia. 3. Staff 1 provided a photo of Resident 1?s injury which included bruising on both eyes and redness, bruising, and a bump in the center of Resident 1?s forehead. 4. Upon review of Staff 2 and Staff 3?s written statements obtained between 10/27/2025 and 10/31/2025, it was determined that Staff 2 noticed the injury around lunchtime, while Staff 3 noticed the injury around 4PM. Additionally, Staff 3?s statement indicated that the day shift (7 AM to 3 PM) including Staff 2, did not indicate any observations. 5. Resident 1?s ISP
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan included an inability to use the signaling device and daily rounds made by care staff were documented. Evidence: 1. In an interview with two LI?s, Staff 1 stated that Resident 1 resided in the safe security unit and did not have access to and could not use a signaling device. 2. Resident 1?s ISP
Jul 28, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/27/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. 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: 07/28/2025 10:15 AM to 12:10 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: 8 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: 0 Number of interviews conducted with staff: 3 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
Based on staff record review and staff interview, the facility failed to ensure that direct care staff met one of the requirements of this subsection at hire or within two months of employment. Evidence: 1. Staff 3 was hired as a direct care staff member on 05/16/2025. 2. Staff 3?s record contains a Personal Care Aide (PCA) training certificate dated 02/20/2021 from [Collateral Contact 1]. The facility was unable to provide documentation Collateral Contact 1 is an approved DMAS training organization. 3. In an interview with the LI on 07/28/2025, Staff 1 and 2 acknowledged that Staff 3 did not meet one of the requirements of the subsection at hire or within two months of employment.
Jul 28, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 07/04/2025 regarding allegations in the area(s) of: 1. Staffing and Supervision 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: 07/28/2025 12:10 PM to 3:45 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: 99 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: 1 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 supported the complaint of non-compliance with standard(s) or law, and violation(s) were 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
Based on facility document review and staff interview, the facility failed to ensure that there was staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident and to ensure compliance with this chapter. Evidence: 1. In an interview with the LI on 07/28/2025, Staff 1 provided a copy of the written staffing plan and scheduling template for Assisted Living Staff for the LI to review. Staff 1 stated that Shift 1 (7AM to 3PM) and Shift 2 (3PM to 11PM) required four (4) direct care staff members and Shift 3 (11PM to 7AM) required three 3 direct care staff members. 2. After a review of the Schedule and the Care Staff Assignments for May 2025 and June of 2025. There were 30 shifts that did not have the required number of staff members. The dates are as follows: a. Shift 1 ? 05/18/2205, 06/10/2025, 06/15/2025, 06/23/2025, 06/25/2025, 06/29/2025 b. Shift 2 ? 05/04/2025, 05/05/2025, 05/09/2025, 05/12/2025, 05/13/2025, 05/18/2025, 05/21/2025, 05/24/2025, 05/25/2025, 06/15/2025, 06/22/2025, 06/28/2025. c. Shift 3 ? 05/04/2025, 05/05/2025, 05/09/2025, 05/10/2025, 05/18/2025, 05/21/2025, 05/24/2025, 06/10/2025, 06/15/2025, 06/22/2025, 06/23/2025, 06/25/2025 3. In an interview with the LI on 07/28/2025, Staff 1 and Staff 2 acknowledged that there were not sufficient staff in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident and to ensure compliance with this chapter.
Based on resident record review and staff interview, the facility failed to ensure care and provision and service delivery was resident centered to the maximum extent possible and included prompt response by staff to resident needs. Evidence: 1. In an interview with the LI on 07/28/2025, Resident 1 stated that Resident 1 had experienced long call bell times, including waiting over an hour on the morning of 07/28/2025. 2. In an interview with the LI on 07/28/2025, Staff 1 stated that the expected response time is 15 minutes. 3. A Resident Event Report was reviewed for Resident 1?s call bell times for the months of June 2025 and July 2025. The report indicated the longest response time was 238 minutes and average response time was 22 minutes. In the report, there were 27 instances that were over 20 minutes. Of those 27 instances, there were 9 instances over an hour, including a 62-minute response time on 07/28/2025 at 6:51 AM. 4. In an interview with the LI on 07/28/2025, Staff 1 and Staff 2 acknowledged that the facility failed to ensure prompt response by staff to resident needs.
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s orders. Evidence: 1. Resident 1?s record contains signed physician orders Amiodarone Tab 200 MG, started 03/04/2025 that state the following, ?Take 1 Tablet by Mouth once daily for AFIB. **HOLD FOR SBO LESS THAN 110 or HR LESS THAN 60.? 2. Resident 1?s June 2025 Medication Administration Record ( MAR
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