Inspection Reports for Elancé at West End
5550 Cardinal Pl, Alexandria, VA 22304, United States, VA
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Inspection Report
Renewal
Census: 58
Deficiencies: 5
Mar 14, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure administrator training in cognitive impairment, inadequate health care oversight frequency, medication orders without valid physician authorization, and lack of semiannual and annual reviews of the emergency preparedness plan.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that the administrator attended at least 12 hours of training in cognitive impairment within three months of employment. |
| Facility failed to provide health care oversight at least every six months; oversight was only annual. |
| Facility failed to ensure that no medication was started without a valid order from a physician or other prescriber. |
| Facility failed to develop and implement a semiannual review on the emergency preparedness and response plan for all staff and residents. |
| Facility failed to review the emergency preparedness plan annually and document with signature and date. |
Report Facts
Number of residents present: 58
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of staff interviews conducted: 3
Number of resident interviews conducted: 0
Residents reviewed in healthcare oversight: 9
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 4
Oct 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-18 regarding allegations related to personnel and resident care and related services at the facility.
Findings
The investigation supported allegations of non-compliance with standards related to medication management, including failure to ensure timely filling and administration of medications, lack of valid physician orders for some medications, and incomplete documentation on the Medication Administration Record (MAR). Violations were issued and corrective actions were required.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting allegations of non-compliance in personnel and resident care related to medication management.
Deficiencies (4)
| Description |
|---|
| Facility failed to implement their written medication management plan to ensure timely filling and refilling of prescription medications and over-the-counter drugs, resulting in missed dosages for Resident 1. |
| Facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued without a valid order from a physician or prescriber; Resident 1 had Vitamin D2 50000U without a current order. |
| Facility failed to ensure medications were administered according to physician's instructions; Resident 1 missed doses of Rytary medication on multiple occasions. |
| Facility failed to ensure the Medication Administration Record (MAR) included the name, signature, and initials of all staff administering medications; multiple unidentified initials were found on Resident 1's MAR. |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 1
Number of staff records reviewed: 6
Number of staff interviews conducted: 3
Number of resident interviews conducted: 0
Missed medication doses: 4
Date of complaint: Sep 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Routine
Census: 70
Deficiencies: 5
Feb 29, 2024
Visit Reason
The inspection was a routine regulatory visit to review multiple areas including administration, personnel, resident care, building and grounds, emergency preparedness, and compliance with additional requirements for adults with cognitive impairments.
Findings
The inspection found multiple violations related to failure to follow weight tracking policies, failure to follow up on dietician recommendations, medication administration errors, lack of physician orders for restraints, and failure to address bedrail use in residents' individualized service plans. Plans of correction were proposed for each deficiency.
Deficiencies (5)
| Description |
|---|
| Facility staff failed to follow the Weight Tracking and Monitoring policy for residents, with missing or outdated weight records. |
| Facility staff failed to follow-up on dietician recommendations to residents' physicians, with no evidence of implementation. |
| Facility staff failed to ensure medications were administered according to physician orders, with multiple missed doses documented. |
| Facility staff failed to obtain physician orders for restraints (bedrails) before use for several residents. |
| Facility staff failed to address the use of bedrails in residents' Individualized Service Plans (ISPs). |
Report Facts
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
Missed medication doses: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector conducting the inspection |
| Margaret Radzikowski | Dietician | Provided dietary recommendations cited in inspection |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Feb 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to staffing and supervision and resident care and related services at the assisted living facility.
Findings
The investigation supported the allegation of non-compliance with standards or law regarding delayed response to resident needs. Specifically, there were 39 instances where nurse call response times exceeded 30 minutes, indicating failure to promptly respond to residents.
Complaint Details
The complaint was substantiated based on resident record review and resident interview. Evidence showed 39 instances between 11/7/2023 and 11/8/2023 where nurse call response times were greater than 30 minutes.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to promptly respond to resident needs, with multiple nurse call response times exceeding 30 minutes. |
Report Facts
Instances of delayed nurse call response: 39
Number of residents present: 70
Number of resident records reviewed: 18
Number of resident interviews conducted: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review administration, staffing, supervision, and building and grounds at the facility.
Findings
The complaint was investigated and determined to be not valid. The Administrator and Licensing Inspector discussed risk assessment ratings for violations during the inspection.
Complaint Details
Complaint was determined not valid.
Inspection Report
Monitoring
Census: 83
Deficiencies: 0
Nov 29, 2023
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review compliance with applicable standards and laws.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and observed medication administration without identifying any deficiencies.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 5
Interviews with residents: 0
Interviews with staff: 0
Inspection Report
Original Licensing
Deficiencies: 0
Sep 5, 2023
Visit Reason
The inspection was an initial licensing inspection conducted to evaluate the facility for compliance with applicable standards and laws.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant and observed emergency preparedness supplies.
Report Facts
Staff records reviewed: 89
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