VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance Alexandria
5100 Filmore Avenue
Alexandria, VA 22311
(703) 845-5100

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: March 29, 2024

Complaint Related: No

Areas Reviewed:

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03.29.2024; Start Time: 10:39 am End Time: 3:31 pm 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI toured the physical plant of the facility, and observed residents involved in independent pursuits. LI 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 703.635.6074or by email at nina.wilson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-660-A-1
Description:	Based on medication pass observation the facility failed to ensure that the medication cabinet was locked prior to walking away to administer medication. Evidence: 03/29/24 LI observed staff to prepare medications, turned to administer the medication but failed to lock the prior to walking away to administer the medication to the resident. LI prompted staff to secure medication cart.
Plan of Correction:	In respect to the specific resident/situation cited: The RMA was provided in-service education on 03/29/2024: Securing the Medication Cart During a Medication Pass. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Medication Pass observations will be completed by the Director of Clinical Services or designee weekly for the next 4 weeks then quarterly, thereafter. With respect to what systemic measures have been put into place to address the stated concern: Random medication cart checks will be completed by the Director of Clinical Services or designee weekly for 4 weeks, then randomly thereafter to verify that medication carts are secured appropriately during medication pass.
Standard #:	22VAC40-73-870-I
Description:	Based on Elance at Alexandria?s records, it was found that the facility failed to provide a certificate of inspection. Evidence: The elevator certificate was dated 03/31/2022.
Plan of Correction:	In respect to the specific resident/situation cited: Elevator repairs for the 4 elevators have been ongoing. Initial repairs began 05/09/2024, additional parts have been ordered with an estimated completion date of 05/30/2024. The City of Alexandria re-inspection is scheduled for June 2024. In respect to how the facility will identify resident/situations with the potential for the identified concerns: The community work order/task list system will be monitored weekly, by the Director of Environmental Services. With respect to what systemic measures have been put in place to address the stated concern: Weekly monitoring of the community work order /task list system, by the Director of Environmental Services to ensure that all inspections are scheduled timely so that any follow up/repairs can be completed, with a re-inspection prior to expiration date of certificates/licenses.