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: Jan. 26, 2021 and Feb. 25, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was completed by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 1/25/2021 and concluded on 2/25/2021. A complaint was received by the department regarding allegations in the areas of staffing quantity, medication administration, and resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation require to complete the investigation. LI reviewed nine resident records. LI interviewed two residents, one family member, and conducted the entrance and exit interviews with the administrator and Resident Care Director. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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 #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based upon a review of resident records, staff work schedule, interviews, and documentation made on the Medication Variance Report by staff, the facility failed to ensure there were staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter. Evidence: The Medication Variance Report (MVR) indicates that the following medications were given more than one hour after the dosing schedule due to med tech administering medications on the 4th floor on 1/3/2021: Resident #1: 8am medications administered at approximately 9:33 am Resident #5: 9am medications administered at approximately 10:55 am Resident #8: 8am medications administered at approximately 9:38am According to the MVR, 4pm medications were administered greater than one hour after the dosing schedule on 1/14/2021 for the following residents because the med tech assigned to administer medications was ?in a meeting at the time.? Resident #3: 4pm medications were administered at approximately 6:10pm Resident #9: 4pm medications were administered at approximately 5:40pm The MVR indicates that on 1/16/2021, 8am and 9am medications were administered greater than one hour after the dosing schedule for the following residents due to "short staff." Resident #3: 8am medications were administered at approximately 1:02pm Resident #4: 9am medications were administered at approximately 12:59pm Resident #5: 8am medications were administered at approximately 11:37am Resident #6: 8am medications were administered at approximately 10:23am Resident #8: 8am medications were administered at approximately 12:38pm Resident #9: 8am medications were administered at approximately 2:49pm According to the work schedule provide by the facility, the staffing assignments for 1/16/2021 had the nurse on duty administering medications to the first floor from 7am to 3pm. The MVR and the January 2021 MARS indicate that the nurse on duty also administered medications to residents on the COVID unit located on the 4th floor (Residents #3,#4,#5,#6,#8, and #9). The shortage of staff on 1/16/2021 resulted in 8am medications being administered greater than one hour after the dosing schedule. On 2/22/2021, LI requested a copy of the January 2021 work schedule that would indicate any changes to the schedule such as call outs or substitutions. LI never received the requested document.
Plan of Correction:	It is duly noted that the staffing may not have been at full capacity for residents 1, 3-7, 8 and 9 to attain and maintain the physical, mental, and psychosocial well-being of each resident during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Executive Director (ED) will review staffing numbers with Resident Services Director (RSD) to ensure sufficient numbers are schedule to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident. The ED shall engage the clinical consultants for process improvement opportunities related to staff.
Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based upon interviews with residents and family members and review of facility reports, the facility failed to provide care and provision of services to residents that includes prompt response by staff to resident needs as reasonable to the circumstances. Evidence: Resident #1 was moved to the COVID unit on 1/8/2021 and according to a collateral contact #1 it had been requested that her lift chair and incontinence pads be moved to the new room as the chair is needed to help with transferring and the incontinence pads to help with bladder incontinence. According to an interview with a collateral contact #1, the chair and the incontinence pads were moved approximately after 1pm on 1/9/2021. Collateral contact #1 reported that Resident #1 needed help in the bathroom on 1/20/2021 and called a family member when there was no response from the staff. According to collateral contact #1 a family member of Resident #1 stayed on the phone for approximately 45 minutes until staff arrived to help. An interview with collateral contact #1 revealed information that during the night of 1/12/2021 and early morning of 1/13/2021, the resident had pressed her call button for help because she could not breathe but no one came quickly. LI requested the Call Bell Response Reports on 2/3/2021 to determine the length of time staff were taking to respond to call bells. LI was not provided the requested report and was informed on 2/11/2021 that a system error had occurred with the call bell system which would not allow retrieval of the requested information. The administrator stated that the call bell system had to be rebooted which ?would cause a loss of date.? Due to the reboot the facility was not able to provide the requested information. Interview with collateral contact #1 reported during the evening of 1/9/2021, a male resident wandered into the room of Resident #1 on the 4th floor COVID Unit. According to collateral contact #1, Resident #1 pushed her call bell multiple times with no response. Resident #1 then walked the male resident down the hall ?without finding anyone in the area.? Collateral contact #1 reported that Resident #1 sat with the male resident and waited for someone to return the area. Collateral contact #1 was unable to state how long Resident #1 had to wait for staff to arrive and did not know the name of the staff person who did arrive. The staff member who came to aide Resident #1 allegedly stated that she was ?covering the 2nd floor that night.? Multiple interviews with collateral contact #2 yielded information regarding a lack of prompt response by staff to resident?s needs in regards to an order from the nurse practitioner (NP). The collateral contact reported that a resident complained of dizziness to the NP on 1/25/2021 and the NP put in a request for staff to take the resident?s vitals on 1/25/2021. Collateral contact #2 indicated that the resident did question staff about the NP?s request for the vitals be checked but the resident?s vitals were never checked.
Plan of Correction:	It is duly noted that resident responses for assistance may have been temporarily delayed during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the care partners on the importance of prompt response to resident needs. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to prompt response by staff to resident needs.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based upon a review of resident records and interviews, the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: According to the Medication Variance Report (MVR) medications for the following residents were administered either greater than one hour before or greater than one hour after the dosing schedule. Resident #1: 6am medications: 1/11/2021?administered at approximately 8:30am 8am medications: 1/2/2021-administered at approximately 10:27am 1/3/2021-administered at approximately 9:33am 1/10/2021-administered at approximately 12:52pm Resident #2: 8am medications: 1/7/2021?administered at approximately 9:28am 1/10/2021-administered at approximately 12:26pm 1/18/2021-administered at approximately 11:19am 8pm medications: 1/17/2021?administered at approximately 10:41pm Resident #3: 8am medications: 1/8/2021?administered at approximately 11:02am 1/10/2021?administered at approximately 12:47pm 1/16/2021?administered at approximately 1:02pm Resident #4: 9am medications: 1/4/2021?administered at approximately 10:17am 1/8/2021?administered at approximately 10:28am 1/16/2021?administered at approximately 12:59pm 8pm medications: 1/17/2021-administered at approximately 1:37pm 1/22/2021?administered at approximately 9:28pm 1/26/2021?administered at approximately 10:54 pm Resident #5: 8am medications: 1/3/2021?administered at approximately 10:55am 1/16/2021?administered at approximately 11:37am 5pm medications: 1/28/2021?were administered at approximately 7:50pm Resident #6: 8am medications: 1/5/2021?administered at approximately 10:30am 1/8/2020?administered at approximately 11:37am 1/11/2021?administered at approximately 12:35pm 1/12/2021?administered at approximately 10:44am 1/15/2021?administered at approximately 9:56am 1/16/2021?administered at approximately 10:23am 1/17/2021-administered at approximately 10:43am 1/182021?administered at approximately 10:05am 9am/9:30am medications: 1/11/2021?administered at approximately 12:35pm 1/12/2021?administered at approximately 10:44am 1/22/2021?administered at approximately 11:04am On 1/30/2021 a medication to be administered between 7am and 2:59pm was administered at approximately 5:05pm 6pm medications: 1/9/2021?administered at approximately 10:10pm 8pm medications: 1/19/2021?administered at approximately 10:22pm 1/20/2021?administered at approximately 10:19pm 1/21/2021?administered at approximately 10:33 pm Resident #7: 2am medications: 1/4/2021?administered at approximately 4:14am 8am medications: 1/5/2021?administered at approximately 10:31am 1/10/2021?administered at approximately 10:06am 1/21/2021?administered at approximately 12pm Resident #8: 8am medications: 1/3/2021?administered at approximately 9:38am 1/10/2021?administered at approximately 11:04am 1/16/2021?administered at approximately 12:38pm 1/17/2021?administered at approximately 1:33pm 5pm medications: 1/22/2021?administered at approximately 6:27pm 1/27/2021?administered at approximately 9:37pm Resident #9: 7:30am medications: 1/3/2021?administered at approximately 10:43am 1/17/2021?administered at approximately 12:57pm 1/22/2021?administered at approximately 8:57am 1/29/2021?administered at approximately 8:55am 8am medications: 1/3/2021?administered at approximately 1:36 pm 1/16/2021?administered at approximately 2:49pm 1/25/2021?administered at approximately 2:18pm 4pm medications: 1/14/2021?administered at approximately 5:40pm 1/22/2021?administered at approximately 6:04pm
Plan of Correction:	It is duly noted that Medication Administration Records (MARS) for residents 1-9 did not consistently include documentation for the timely administration of medications during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the medication care partners on the importance of timely administration of medications and treatments including timely documentation. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to timely administration of medications.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
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: Resident #2?a physician?s order for 9 units of Humalog to be given at approximately 8am was written on 1/10/2021, according to the January 2021 Medication Administration Records (MARS). The MARS indicates that on January 17, 2021 at approximately 8am, Resident #2 did not receive the dosage of the current order for 9 units of Humalog but received a discontinued order for a 13 unit dosage of Humalog. The physician?s order for the 13 units of Humalog to be given at 8am was, according to the MARS, stopped on 1/5/2021. On 2/16/2021 the Licensing Inspector (LI) requested a copy of the physician?s order to discontinue the 13units of Humalog at 8am. The facility did not provide the requested physician?s discontinuation order. A physician?s order for 4units of Humalog to be administered at approximately 8pm was written, according to the MARS, on 1/13/2021. The MARS indicates that on 1/15/2021 and 1/16/2021, Resident #2 did not receive the current ordered dosage of 4units of Humalog but received a discontinued order for 8units of Humalog to be given at approximately 8pm. The physician?s order for 8 units of Humalog to be administered at approximately 8pm was stopped, according to the MARS, on 1/5/2021. On 1/13/2021 and 1/14/2021, the MARS indicates that Resident #2 was administered at approximately 8pm the current order of 4 units of Humalog in addition to the discontinued order of 8 units of Humalog. On 2/16/2021 the Licensing Inspector (LI) requested a copy of the physician?s order to discontinue the 8units of Humalog at 8pm. The facility did not provide the requested physician?s discontinuation order. Resident #1:-- According to the January 2021 MARS, Resident #1 had a physician's order for Famotidine 20milligrams (mg) twice a day for four weeks to be given at approximately 8am and 8pm. A physician?s order for Famotidine 20mg, two tablets daily to be given at approximately 9am, had been written on 4/10/2020. On 1/10/2021, Resident #1 was administered one 20mg tablet of Famotidine and two 20mg tablets of Famotidine at approximately 12:52pm. On 1/11/2021, 1/12/2021, and 1/13/2021, Resident #1 was administered one 20mg tablet of Famotidine at approximately 8am and two 20mg tablets at approximately 9am, according to the January 2021 MAR. On 2/16/202 and 3/9/2021, LI requested a copy of the discontinuation order for Famotidine 20mg two tablets once a day, but the facility failed to provide the physician?s discontinuation order.
Plan of Correction:	It is duly noted that documentation for residents 1,2 reflects medications were not delivered in accordance with the physician's instructions and consistent with the standards of practice as outlined in the current registered medication aide curriculum by the Virginia Board of Nursing during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the medication care partners on insulin management and importance of double checking for new orders, particularly with high risk medications. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to time medication administration.
Standard #:	22VAC40-73-680-E
Complaint related:	Yes
Description:	Based upon a review of resident records, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions. Evidence: Resident #3: A physician's order was written on 10/16/2020 for resident to be repositioned "every two hours for skin breakdown treatment." The Medication Variance Report (MVR), is a report obtained from the facility?s electronic medication system CareSuite by Quick Mar and is used to document the exact times of medication administration, administration of treatment orders, and administration of orders for vitals was reviewed. According to the MVR, repositioning was not completed as ordered by physician for the following dates and times: 12 am repositioning: 1/19/2021?completed at approximately 2:36 am 1/27/2021?completed at 3:53am, at the same time as the 2am repositioning 1/28/2021?completed at 3:00am, at the same time as the 2am repositioning 2 am repositioning: 1/12/2021?completed at approximately 4:05am 1/13/2021?completed at approximately 3:57am 1/21/2021?completed at approximately 5:42am, at the same time as the 4am repositioning 1/27/2021?completed at 3:53am, at the same time as the 12 am repositioning 4 am repositioning: 1/16/2021?completed at approximately 5:36am 1/21/2021?completed at approximately 5:42am 8 am repositioning: 1/8/2021?completed at approximately 11:02am, same time as the 10am repositioning 1/10/2021?completed at approximately 1:59pm, same time as the 10am and 12 pm repositioning 10am repositioning: 1/10/2021?completed at approximately 1:59pm, same time as the 8am and 12pm repositioning 1/16/2021?completed at 1:02pm, same time as the 12pm repositioning 12pm repositioning: 1/10/2021?completed at approximately 1:59pm same time as the 8am and 10am repositioning 1/16/2021?completed at approximately 1:02pm, same time as the 10am repositioning 2pm repositioning: 1/18/2021?completed at approximately 9:18am 4pm repositioning: 1/14/2021?completed at approximately 6:10pm 8pm repositioning: 1/15/2021?completed at approximately 10:22pm Resident #2-A physician?s order was written on 1/7/2021 for blood sugar to be checked and recorded before meals and at bedtime for diabetes. Blood sugar checks and recordings were not administered according to the physician?s order for the following dates and times: 7:30am blood sugar checks 1/10/2021-completed at approximately 12:36pm 1/18/2021-completed at approximately 11:19am 1/22/2021-completed at approximately 10:30am 11:30am blood sugar checks: 1/22/2021-completed at approximately 12:54 pm 4:30pm blood sugar checks: 1/22/2021?completed at approximately 6:47pm
Plan of Correction:	It is duly noted that resident 3 did not have medical procedures or treatments ordered by a physician documented in the health record during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the medication care partners on the importance of following physician's orders for procedures or treatments. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to the importance of following physician's orders for procedures and treatments.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based upon a review of resident records, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: The Medication Variance Report (MVR) indicates that documentation of the administration of medications was not done at the time of administration for the following residents: Resident #2: 1pm medications (Prednisone) 1/8/2021?the documented time given was approximately 2:39pm but staff noted on MVR that medication was ?given on time late entry.? 2pm medications (Sodium Bicarb) 1/30/2021?the documented time given was approximately 5:04pm but staff noted on MVR that medication was ?given on time late entry.? 8pm medications (Humalog, Simvastatin, Sodium Bicarb) 1/21/2021?the documented time given was approximately 9:31pm but staff noted on MVR that medications were ?given on time.? 1/26/2021-the documented time given was approximately 9:36 pm but staff noted on MVR that medications ?given on time late entry.? Resident #3: 8am and 9am medications (Acetaminophen, Ascorbic Acid, Chlorhexidine, Donepezil, Eliquis, Sertraline, Triple Antibiotic Ointment, Vit. D3, and Zinc Gluconate): 1/17/2021-the documented time given was approximately 1:40pm but staff noted on MVR that medications were ?given on time late entry.? 8pm and 9pm medications (Chlorhexidine, Eliquis, Verapamil, 1/8/2021?the documented time given was approximately 10:06 pm but staff noted on MVR that medications were ?given on time late entry.? 1/10/2021?the documented time given was approximately 10:10pm but staff noted on MVR that medications were ?given on time but late entry.? 1/20/2021?the documented time given was approximately 10:16/10:17pm but staff noted on MVR that medications were ?given on time but late entry.? Resident #4: 8am medications (Amlodipine, Aspirin, Donepezil, Memantine, Sertraline, Tamsulosin HCL, Vit. D3, and Zinc Gluconate) 1/14/2021?the documented time given was approximately 9:37am but staff noted on MVR that medications were given ?on time.? Resident #5: 6pm medications (Propranolol, Simvastatin) 1/16/2021-the documented time administered was approximately 7:56pm but staff noted on MVR that medication was ?given on time late entry.? Resident #6: 8am medications and 9:30 am medications (Artificial Tears, Aubagio, Baclofen, Calcium 600+VitD, Digestive Advantage Lactose, Docusate, Evening Primrose Oil, Fexofenadine HCL, Fluticasone spray, Olopatadine HCL, One Daily for Women, Turmeric Caps, Vit. D, and Vit. D3) 1/7/2021?the documented time administered was 2:05 pm but staff noted on MVR that medications were ?gave on time.? 5pm medications (Baclofen) 1/26/2021?the documented time administered was approximately 9:38pm but staff noted on MVR that medications were administered as ?given on time late entry.? Resident #7: 8am medications (Acetaminophen, Ascorbic Acid, Barrier Cream, Cranberry, Famotidine, Ferrous Sulfate, Memantine, Multi-vitamin, Omeprazole, Polyethylene Glycol, Quetiapine Fumarate, Senna Plus, Symbicort, Tramadol, Venlafaxine HCL, Vitamin B-12, Vitamin D3, and Zinc Sulfate) 1/1/2021-the documented time administered was approximately 12:34 pm but staff noted on MVR that medications were ?on time late entry.? Due to the volume of information gathered, a separate document has been created and is available upon request from the Fairfax Licensing Office.
Plan of Correction:	It is duly noted that the Medication Administration Records (MARS) did not consistently include the time medications were administered to residents 2, 3,6,7, and 9 during the time period in which the community was experiencing a COVID 19-virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the medication care partners on the importance of timely administration of medications and treatments including timely documentation. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to timely medication administration documentation.
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based upon a review of resident records, the facility failed to ensure that the Medication Administration Records (MARS) shall include: initials of direct care staff administering the medication. Evidence: The January 2021 Medication Administration Records (MARS) did not include the initials of the staff person administering the medications for the following residents on the following dates: Resident #3: 12am medications (Acetaminophen) 1/11/2021?the initials of the staff person administrating the medication were missing on the MARS 1/17/2021?the initials of the staff person administering the medications were missing on the MARS 6:30am medications (Levothyroxine) 1/17/2021?the initials of the staff person administering the medications were missing on the MARS 1/30/2021?the initials of the staff person administering the medications were missing on the MARS 1/31/2021?the initials of the staff person administering the medications were missing on the MARS 4pm medications (Acetaminophen) 1/2/2021?the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by Staff #1. 8pm medications (Eliquis, Magic Mouthwash, Verapamil) 1/2/2021-the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by Staff #1 Resident #4: 8am medications (Amlodipine, Ascorbic Acid, Aspirin, Donepezil, Ensure, Memantine, Mucinex, Sertraline, Tamsulosin, Vit. D3, and Zinc Gluconate) 1/17/2021-- the initials of the staff person administering the medications were missing on the MARS Resident #6: 6:30am medications (Levothyroxine) 1/18/2021- the initials of the staff person administering the medications were missing on the MARS 9:30am medications (Artificial Tears, Aubagio, Baclofen, Calcium 600+VitD, Digestive Advantage Lactose, Docusate, Evening Primrose Oil, Fexofenadine HCL, Fluticasone spray, Olopatadine HCL, One Daily for Women, Turmeric Caps, Vit. D, and Vit. D3) 1/9/2021?The Medication Variance Record (MVR) indicates that the person administrating the medications was the nurse on duty, but the initials on the MARS document it was the med tech who administered the medications. 6pm medications (Baclofen) 1/5/20210- the initials of the staff person administering the medications were missing on the MARS 1/8/2021-- -the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by the nurse on duty. 1/10/2021-- -the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by the nurse on duty. 1/15/2021-- the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by the nurse on duty.. 1/16/2021-- the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by the nurse on duty. Resident #7: 2am medications (Acetaminophen) 1/8/2021-- the initials of the staff person administering the medications were missing on the MARS 6am medications (Levothyroxine) 1/8/2021-- the initials of the staff person administering the medications were missing on the MARS 1/11/2021-- the initials of the staff person administering the medications were missing on the MARS 1/18/2021-- the initials of the staff person administering the medications were missing on the MARS Resident #9: 2pm medications (Ascorbic Acid) 1/22/2021-- the initials of the staff person administering the medications were missing on the MARS
Plan of Correction:	It is duly noted that the Medication Administration Records (MARS) did not include initials of direct care staff administering medications to residents 3, 4, 6, and 7 during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area. The Resident Services Director (RSD), or designee, will re-educate the medication care partners on ensuring their initials are documented on the MARS. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to initials on the MARS.