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: Yes

Areas Reviewed:

Staffing and Supervision Resident Care and Related Services

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/29/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 18 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to Resident Care and Related Services and Staffing and Supervision, but identified during the course of the investigation can also be found on the violation notice. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	No
Description:	Based on resident record review and resident interview, the facility staff failed to promptly respond to resident?s needs. Evidence: ? According to the Detailed Event Report for the nurse call light response times there were 39 instances between 11/7/2023 and 11/8/2023 in which the nurse call response time was greater than 30 minutes. The following residents rang for assistance using their nurse call pendant, all listed below were answered after 30 minutes: ? Res A on 11/7/2023 at 1:18am, 4:43am, 7:36am, 12:48am, 2:40pm, 4:25pm, 6:13pm, 7:05pm, 9:51pm and on 11/8/2023 at 4:13pm and 9:26pm ? Res B 0n 11/7/20283 at 7:36am ? Res C on 11/7/2023 at 12:44pm ? Res D on 11/7/2023 at 12:53pm and on 11/8/2023 at 1:13am and 8:26am ? Res E on 11/7/2023 at 3:44pm and on 11/8/2023 at 1:46pm ? Res F on 11/7/2023 at 4:16pm, 6:22pm and on 11/8/2023 at 2:44pm ? Res G on 11/7/2023 at 5:38pm and on 11/8/2023 at 9:16am ? Res H on 11/7/2023 at 6:00pm ? Res I on 11/7/2023 at 7:20pm ? Res J on 11/7/2023 at 8:08pm ? Res K on 11/8/2023 at 5:11am and 9:51am ? Res L on 11/8/2023 at 9:14am ? Res M on 11/8/2023 at 9:38am ? Res N on 11/8/2023 at 10:11am ? Res O on 11/8/2023 at 12:40pm ? Res P on 11/8/2023 at 12:45pm ? Res Q on 11/8/2023 at 7:27pm and 9:26pm ? Res R on 11/8/2023 at 7:45pm ? Res S on 11/7/2023 at 8:05pm
Plan of Correction:	Immediate Actions Taken: ED met with each resident and/or their responsible party to address the extensive pendant response time. Additionally, community wide improvement plan for pendant response time was addressed to all residents who attended Resident Council on 4/25/2024 and Coffee and Chat with the ED on 4/10/2024. Plan for Continued Compliance: Pendant Response Time Report is generated daily and sent to ED and DCS for review and follow up over the next 30 days and will then be routinely reviewed during daily Manager?s Meeting thereafter.