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Tribute at One Loudoun, LLC
20335 Savin Hill Drive
Ashburn, VA 20147
(571) 252-8292

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Jan. 23, 2020 and Jan. 24, 2020

Complaint Related: No

Areas Reviewed:

An unannounced focused monitoring study was conducted on 1/23/2020 and 1/24/2020 regarding a self-reported incident and to ensure corrections of previous violations cited at a focused monitoring inspection conducted 11/21/19. Resident records, medication administration records, and staff records were reviewed. Interviews were conducted. Violations were discussed at exit interview held on 1/29/2020. LI is recommending an intensive plan of correction.

Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days.

Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s).

Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at

Standard #: 22VAC40-73-640-A
Description: Based upon a review of resident records, other documentation, and interviews with staff, the facility failed to implement their written plan for medication management.The facility failed to to follow methods verifying that medication orders have been accurately transcribed to medication administration records (MARS) within 24 hours of receipt of a new order or change in an order and failed to ensure of proper disposal of medications that have been discontinued.

Evidence: On 12/31/19 physician's orders for Resident #2 were entered under the medication administration record for Resident #1. The medication management plan for the facility states "upon receipt of a physician's order to discontinue a medication, the Health and Wellness Director or medications staff will: remove the discontinued medication from the medication storage cart/cabinet and store in the designated secure area for drugs awaiting return/ destruction." The facility failed to remove the discontinued medication order dated 9/19/19 for Gabapentin 100mg (1 capsule twice a day) from the medication cart/cabinet. According to the Individual Resident's Controlled Substance Record (IRCSR), Resident #1 received three 100mg capsules of Gabapentin between 9/22/19 and 10/22/19.

Plan of Correction: Every discontinued medication will be sent back daily to the pharmacy, Express Care. Educated all medication teams on process for discontinued and new order medications on 2/4/2020. Vice President of Resident Experience (VPRX) will do random audit of all new orders weekly for the next 90 days. Next training will include making sure medication team members are letting the resident know what the medications are called and what they are for. VPRX conducting weekly medication passing rounds with notes. Completed 22 random resident medication administration records (MAR) to cart audit for discontinued medication orders and new orders as of 2/10/2020. Will complete MAR to cart audit for entire resident population by 5/10/2020.

Standard #: 22VAC40-73-680-D
Description: Based upon a review of medical records, other documents, and interviews, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.

Evidence: Physician's orders for Resident #2 were entered in error for Resident #1. Resident #1 received the following medications for approximately six days that were prescribed for Resident #2: Acidophilus Probiotic Capsule (1 capsule daily for two weeks); Aspirin-Dipyridam ER (25-200mg 1 capsule every 12 hours); Cefuroxime Axetil (500mg 1 capsule every 12 hours); Centrum Silver 50+(1 tablet daily); Furosemide (20mg 1 tablet daily), Latanoprost Eye Drops (0.005% 1 drop into each eye at night); Magnesium Oxide (400mg 1 tablet daily); Melatonin (3mg 2 tablets at night); Memantine (10mg 1 tablet every 12 hours);Metronidazole (500mg 1 tablet three times a day); Mirtazapine (7.5mg 1 tablet daily); Nortriptyline HCl (10mg 1 capsule daiy); Olanzapine (5mg dissolve 1 tablet under tongue daily); and Potassium CL ER (10meq 1 tablet daily). For approximately four days, Resident #1 did not receive Rytary ER (48.75mg-195mg, 1 capsule three times a day) for which there was an active physician's order. For approximately six days, Resident #1 did not receive the following medications, for which there were active physician's orders: Acetaminophen (500mg 2 tablets twice a day); Aspirin 81mg chewable (1 tablet daily); Atorvastatin (20mg 1 tablet daily); Ferrous Sulfate (325mg 1 tablet daily); Finasteride (5mg 1 tablet at bedtime); Midodrine HCl (2.5mg 1 tablet daily);Potassium CL (20meq, 1 tablet two times a day); Quetiapine Fumarate (25mg 1 tablet at bedtime); and Rivastigmine (1.5mg 1 capsule twice a day)

Plan of Correction: Three part plan of correction to include pharmacy, medication team members, med techs, and nurses: 1. Express Care Pharmacy added a nickname to Resident #1's profile so as to clearly distinguish from Resident #2 on the Medication Administration Profile (MAR). Also, pharmacy will have alerts pop up with these two residents. Adding name, nickname (if applicable), room number, doctor, and date and time to all orders sent into the pharmacy for verification purposes. Met with pharmacy on 2/6/2020. Pharmacy will conduct quarterly pharmacy audits. Ordering "name alert" stickers for two residents and any others that share the same last names by 2/14/2020. 2. Medication team members, specifically nurses, approving medication changes in the MAR to be re-educated on only approving medication changes in the MAR when the physician's order is in hand. Re-educated on 2/4/2020. Nurses will check all new orders and discontinued orders at start of shift against the MAR and physical order and then again at the end of shift. Weekly auditing by VPRX and designated medication team member. Training provided on 2/4/2020. Will continue weekly training. Every medication room will have a medication "in box" for all new and discontinued medications effective 2/14/2020. Doctors and vendors educated on new process by 2/14/2020. 3. Medication team members including med techs were trained on reporting significant medication changes to include when there have been significant changes to dosing, frequency, and names of medications. Educated to not give medication and report immediately to the nurse on duty on 2/4/2020/

This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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