Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 70
Deficiencies: 4
Mar 26, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to maintain current CPR certification for direct care staff, failure to update individualized service plans timely, failure to administer medications according to physician orders, and failure to ensure elevators were inspected annually and in good working condition.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that each direct care staff member maintained current certification in first aid from approved organizations. |
| Facility failed to review and update the individualized service plan (ISP) at least once every 12 months and as needed for significant changes. |
| Facility failed to ensure medications were administered in accordance with physician's instructions and standards of practice. |
| Facility failed to ensure elevators were in good running condition and inspected annually; elevator inspection expired in 2022 and phone line was not working. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 1
Number of staff interviews: 2
Date of elevator inspection expiration: Mar 31, 2022
Inspection Report
Renewal
Deficiencies: 0
Feb 6, 2025
Visit Reason
The inspection was conducted as a renewal visit triggered by a complaint received on 2024-11-25 regarding allegations in Administration and Administrative Services and Admission, Retention and Discharge of Residents.
Findings
The licensing inspector toured the facility, observed residents participating in activities and dining, and reviewed resident records. The evidence gathered did not support the allegations of non-compliance with standards or law.
Complaint Details
A complaint was received on 2024-11-25 regarding allegations in Administration and Administrative Services and Admission, Retention and Discharge of Residents. The investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Renewal
Census: 73
Deficiencies: 2
Mar 29, 2024
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards, including failure to secure the medication cabinet during medication pass and failure to provide a current elevator inspection certificate. Violation notices were issued with plans of correction required.
Deficiencies (2)
| Description |
|---|
| Based on medication pass observation the facility failed to ensure that the medication cabinet was locked prior to walking away to administer medication. |
| Based on Elance at Alexandria's records, it was found that the facility failed to provide a certificate of inspection for the elevator; the certificate was dated 03/31/2022. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 4
Number of staff records reviewed: 6
Number of interviews conducted with staff: 1
Medication Pass observation education date: Mar 29, 2024
Elevator repairs start date: May 9, 2024
Estimated elevator repair completion date: May 30, 2024
Inspection Report
Monitoring
Census: 79
Deficiencies: 0
Jan 3, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various administrative, personnel, resident care, and facility standards.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant, reviewed resident records, conducted staff interviews, and observed meal and medication administration.
Report Facts
Number of resident records reviewed: 3
Number of interviews conducted with staff: 2
Inspection Report
Original Licensing
Census: 95
Deficiencies: 0
Jul 7, 2023
Visit Reason
An unannounced initial inspection was conducted to review compliance with regulations for an assisted living facility.
Findings
The inspection included review of building and grounds, facility documentation, and records. No violations were cited during the inspection.
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