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: Feb. 1, 2022 and Feb. 4, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.

Comments:

An unannounced renewal study began on 2/1/2022 and ended on 2/4/2022. At the time of entrance 90 residents were in care. The sample size consisted of 10 resident records, five staff records, and six pet records. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 3/19/2021 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including daily chronicle and exercises. Medication administration was observed. Violation notice issued, risk ratings reviewed and exit interview held. 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 #:	22VAC40-73-640-A
Description:	Based upon a review of records, the facility failed to ensure that the written medication management plan was implemented to ensure that each resident's prescription medications are refilled in a timely manner to avoid missed dosages. Evidence: The medication management plan states that medications will be reordered seven days prior to "running out" in order to avoid missed dosages. 1. The February 2022 Medication Administration Record (MAR) for Resident #4 indicates that on 2/1/2022, the resident did not receive the scheduled morning dose of Aspirin EC 81 milligrams (mg) because "med not available, waiting for pharmacy to deliver." 2. The February 2022 MAR for Resident #7 indicates that on 2/1/2022, the resident did not receive the scheduled dose of Ozempic 1mg (4mg/3mL) to be administered subcutaneously once a week on Tuesdays because "med not available; waiting for it to be delivered."
Plan of Correction:	It is duly noted that the facility did not follow the facility's medication management policy with regards to reordering medications seven days prior to running out for Resident #4 and #7. All medication care partners and nurses were re-educated on the facility's Medication Refill Policy by March 11, 2022. The Resident Services Director (RSD) or designee, will conduct monthly medication administration audits and weekly medication cart audits to ensure all medications are available to administer as prescribed by the physician.
Standard #:	22VAC40-73-680-C
Description:	Based upon a review of records, 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 physician's order, Resident #6 is to receive Oxycodone HCl 15mg every four hours. The dosing schedule on the Medication Administration Record indicates that the medication is to be administered at 12am (midnight), 4am, 8am, 12noon, 4pm, and 8pm. The Individual Controlled Substance Record indicates that on the following dates, Resident #6 received Oxycodone more than an one hour after the ordered dosing schedule: 1. On 1/09/2022, the 4am dosage of Oxycodone was administered at approximately 6:10am. 2. On 1/10/2022, the 4 am dosage of Oxycodone was administered at approximately 6:10am. 3. On 1/10/2022, the 8am dosage of Oxycodone was administered at approximately 9:39am. 4. On 1/10/2022, the 12noon dosage of Oxycodone was administered at approximately 1:56pm.
Plan of Correction:	It is duly noted that the facility did not follow the facility's medication management policy when administering medications late four times on two days for Resident #6. The Resident Services Director (RSD), or designee, will re-educate nurses and medication care partners on the facility's medication management policy by March 11, 2022. A medication refresher course will be held for the medication care partners. Medication administration will be monitored by RSD, or designee to endure prescribed medications are given as physician's ordered.
Standard #:	22VAC40-73-680-D
Description:	Based upon a review of 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: 1. The January 2022 Medication Administration Record (MAR) for Resident #6 documents that on 1/3/2022 the resident did not receive the 4am scheduled dose of Oxycodone HCL 15mg. The Individual Controlled Substance Record indicates that the the 4am dosage was not administered to Resident #6 on 1/3/2022.
Plan of Correction:	It is duly noted that the facility did not follow the facility's medication management policy for Resident #6 on 1/3/2022 due to a staffing challenge created when the scheduled medication care partner did not report to work and the Resident Services Director (RSD) was not notified in order for a replacement to be found. The care partners and medication care partners will be re-educated on following the posted staff schedule as well as how and when to notify the RSD, if there are any missing staff members on a given shift. In addition, an audit will be completed on all narcotic medication administration records by February 14, 2022, to ensure that all medications are given as prescribed by the physician's orders. All narcotic medication administration records will be audited monthly by the RSD, or designee, to ensure compliance. The RSD, or designee, will re-educate nurses and medication care partners on the facility's medication management policy by March 11, 2022.
Standard #:	22VAC40-73-930-D
Description:	Based upon a review of records and interview with administrative staff, the facility failed to ensure that for each resident with an inability to use the signaling device, this inability shall be included in the resident's individualized service plan and the plan shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. Evidence: The Memory Care Director (MCD) confirmed during an interview on 2/2/2022 that Resident #5 does not have the capacity to use the call bell system. The Individual Service Plan for Resident #5 did not include the inability of the resident to use the call bell system and did not identify the minimal frequency of rounds to be made by direct care staff to monitor for emergencies or other unanticipated needs for Resident #5.
Plan of Correction:	It is duly noted that the facility did not include in Resident #5 Individual Service Plan (ISP), the inability to use the call bell system and did not identify the minimal frequency of rounds to be made by direct care staff to monitor for emergency or other unanticipated needs for Resident #5. Resident #5's ISP will be updated by the Memory Care Director or designee to reflect the inability to use a call bell system and will include the minimum frequency of rounds by direct care staff to monitor for emergencies or other unanticipated needs of the resident by February 14, 2022. The Memory Care Director or designee will audit all Memory Care residents ISP's to ensure that the inability to use the call bell system is addressed with frequency of rounds by direct staff to monitor for emergencies or other unanticipated needs of the residents by February 28, 2022. All new Memory Care residents will be assessed by the Memory Care Director or designee for the capability to use the call bell system and will have the capability addressed on their ISPs. The residents will be reassessed every six months or whenever there is a change with findings addressed on the ISP.