VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Dec. 14, 2020 and Jan. 26, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 12/14/2020 and concluded on 01/26/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator was contacted by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. LI reviewed two residents records and the staff work schedule. LI interviewed the resident care coordinator. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. The exit interview was completed by telephone on 1/26/2021 with the administrator and resident care coordinator. 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 jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-650-A
Description:	Based upon a review of resident records and interview with administration, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: On 11/23/2020, a physician's order for Resident #1 was written for Trazadone 25mg (milligrams) by mouth twice a day. The December 2020 Medication Administration Record indicated that the order was discontinued on 12/02/2020. No physician's order for the discontinuation of the Trazadone 25mg by mouth twice a day was found in the record of Resident #1.
Plan of Correction:	It is duly noted that no order to discontinue from the physician was found for the Trazadone 25mg for Resident #1 on 12/2/2020. It is duly noted that the medication was discontinued with no negative outcome for the resident. The Resident Services Director (RSD), or designee, will re-educate the team member that discontinued the medication without a written order on ensuring that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed or discontinued by the facility without a valid order from a physician or other prescriber. The RSD, or designee, will re-educate medication technicians on ensuring that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. The Consultant Pharmacist will conduct a review of medication carts and resident records.
Standard #:	22VAC40-73-680-D
Description:	Based upon a review of resident records, 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: According to the physician's order, Lorazepam is to be administered to Resident #2 as follows: 1mg (milligram) 1 Tablet by mouth twice a day as needed. The December 2020 Medication Administration Record (MAR) documented that on 12/1/2020, Resident #2 received 1mg of Lorazepam three times at approximately 10:31 am, 5:45 pm, and 8:31 pm. No negative reaction to the extra dosage were documented.
Plan of Correction:	It is duly noted that on 12/2/2020, Resident #2 received three doses of Lorazepam 1mg and that this dosage was administered outside the physician's order to administer twice a day. It is duly noted that the resident did not have any negative reaction to the extra dose. The Resident Services Director (RSD), or designee will re-educate the team member that administered the medication on medication administration and following physician's or other prescriber's instructions. The RSD, or designee, will re-educate medication technicians on medication administration and following physician's or other prescriber's instructions. The Consultant Pharmacist will conduct a review of medication carts and resident records. The Consultant Pharmacist, or designee, will conduct a medication pass observation for Medication Care Partners.