VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at West End
5550 Cardinal Place
Alexandria, VA 22304

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Feb. 29, 2024

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds Emergency Preparedness Additional Requirements for Facilities that Care for Adults with Cognitive Impairments Background Checks for Assisted Living Facilities Sworn Statement

Comments:

Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI team toured the physical plant of the facility, and observed residents involved in independent pursuits. This LI team also observed a medication pass. Additional Comments/Discussion: 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. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on resident records review and staff interview, the facility staff failed to follow the facility?s Weight Tracking and Monitoring policy. The policy states that ?All assisted living residents will be weighed upon move-in and quarterly unless a significant weight change is noted.? Evidence: Resident D?s last weight was obtained on 11/15/2023, Res E?s last recorded weight was on 9/19/2019, Res F?s last recorded weight was on 6/29/2021, and Res H had no recorded weights from January 1- December 31, 2023. Staff interviewed stated there were no other weights documented in Resident D, E, F or H?s medical record.
Plan of Correction:	A.) With respect to the specific resident/situation cited: Resident E and H weights have been obtained since survey visit. Resident D and F remain pending per residents? request. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: Director of Clinical Services and/or designee will review all resident records within the next 4 weeks for recent weights to identify follow up and updates as needed which may include Responsible Party and Physician notification if unable to obtain weight. A weight verification within 24 hours will be obtained for significant variances. Routine weight obtainment and review will be completed quarterly thereafter. C.) With respect to what systemic measures have been put into place to address the stated concern: Director of Clinical Services and/or designee will establish routine schedule for resident weight to be completed on a quarterly basis. Director of Clinical Services and/or designee will hold staff meeting to establish and review weight monitoring expectation moving forward.
Standard #:	22VAC40-73-620-B
Description:	Based on resident records review and staff interview, the facility staff failed to follow-up on the Dietician?s recommendations to the resident?s physician. Evidence: Dietary Report completed on February 12, 2024, by, Margaret Radzikowski, contained documentation for: ? Resident C recommending change diet to Regular, regular textures, think liquids. ? Resident G recommending discontinue NAS diet. Start No Concentrated Sweets diet. Staff D stated there was no documentation of the communication from the facility to the physician regarding dietary recommendations from the dietician for Resident C or G. Review of resident records and physician orders for Resident C and G did not show evidence of implementation of dietary recommendations from February 12, 2024 Dietician report.
Plan of Correction:	A.) With respect to the specific resident/situation cited: Physicians for residents C and H have been notified of dietitian recommendations. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Director of Clinical Services and/or designee will complete full review of dietitian recommendations from February visit within the next 4 weeks then quarterly thereafter to verify appropriate follow ups are completed. C.) With respect to what systemic measures have been put into place to address the stated concern: The Director of Clinical Services and/or designee have reached out to consulting dietitian to open line of communication for subsequent visits and best process to communicate recommendations to ensure timely follow up.
Standard #:	22VAC40-73-680-D
Description:	Based on resident records review and staff interview, the facility staff failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s orders. Evidence: Resident A had a prescription dated 11/16/2000 for Atorvastatin 10 mg Tablet, take 1 tablet by mouth at bedtime. The January 2024 and February 2024 Medication Administration Record (MAR) contained documentation that the medication was not administered on January 10, January 11 January 19, January 29, January 31, or February 2.
Plan of Correction:	A.) With respect to the specific resident/situation cited: New Director of Clinical Services and/or designee will hold refresher in-service with the Nursing team on medication management expectations which includes managing supplies, availability and appropriate notifications when supplies are low. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: Director of Clinical services and/or designee will perform weekly medication administration audit weekly for 4 weeks then randomly thereafter to verify all medications are administered ordered. C.) With respect to what systemic measures have been put into place to address the stated concern: Director of Clinical Services and/or designee will follow up with assigned staff weekly for any discrepancies noted during the review and issue appropriate corrective actions.
Standard #:	22VAC40-73-710-B
Description:	Based on resident records review and staff interview, the facility staff failed to obtain a physician?s order for a restraint (bedrail) before the restraint was used. Evidence: Resident D, E and F did not have an order from a physician to use a restraint (bedrail) on file.
Plan of Correction:	A.) With respect to the specific resident/situation cited: Orders for bedrail have been obtained for residents D, E and F. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Director of Clinical Services and/or designee will collaborate with the nursing team to complete full audit and inspection within the next 4 weeks then monthly thereafter of residents who may have bedrails and review for physician orders as applicable. C.) With respect to what systemic measures have been put into place to address the stated concern: The Director of 05/31/2024 Clinical Services and/or designee will hold staff meeting to review with nursing staff the importance of identifying residents who are using bedrails and communicating with their supervisor to verify all process are in place in accordance with the policies and regulations. The Director of Clinical Services and/or designee will complete audit of resident with siderails monthly during QA meeting and review continued need and appropriateness of usage during comprehensive annual reassessments.
Standard #:	22VAC40-73-710-E
Description:	Based on resident records review and staff interview, the facility staff failed to address the use of bedrails on the resident?s Individualized Service Plan (ISP). Evidence: Resident D, E and F?s ISP did not address the use of bedrails
Plan of Correction:	A.) With respect to the specific resident/situation cited: ISPs for residents D, E and F have been updated to reflect plan of care for bedrails usage. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Director of Clinical Services and/or designee will collaborate with the nursing team to complete full audit and 05/31/2024 inspection within the next 4 weeks then monthly thereafter of residents who may have bedrails and review ISPs as applicable. C.) With respect to what systemic measures have been put into place to address the stated concern: The Director of Clinical Services and/or designee will hold staff meeting to review with nursing staff the importance of identifying residents who are using bedrails and communicating with their supervisor to verify all process are in place in accordance with the policies and regulations. The Director of Clinical Services and/or designee will complete audit of resident with siderails monthly during QA meeting and review continued need and appropriateness of usage during comprehensive annual reassessments.