VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cambridge Crossing Assisted Living
251 Patriot Lane
Williamsburg, VA 23185
(757) 220-4014

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Sept. 18, 2023 and Sept. 29, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring An on-site Monitoring Inspection conducted with two inspectors from the Peninsula Licensing Office. Ar (08:01a.m./dep 5:05 p.m. The facility census was 13. A tour of the facility was conducted, emergency preparedness/fire drills, resident emergency documents reviewed, staff and resident interviews conducted and records reviewed, medication pass observation, breakfast meal and emergency preparedness supplies observed: The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at wilie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad or fire department. Evidence: 1. On 9-18-23, the first aid and cardiopulmonary resuscitation (CPR) posting noted staff #7?s first aid/CPR expired 08/2023. 2. Staff #1 sent a copy of staff #7?s certification via email on 9-23-23. The certification did not inc
Plan of Correction:	All direct care staff will remain current in first aid from a Virginia approved vendor. Executive Director and/ or Designee will audit employee files monthly to ensure all direct care employees are current in first aid and will work with employees if certification is close to expiration date.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within 30 days preceding the admission, a person shall have a physical examination by an independent physician. Evidence: 1. On 9-18-23, resident #2?s record noted a date of admission of 3-31-23. The physical examination in the record was dated 4-4-23. 2. Staff #1 and CS-1 acknowledged the resident?s physical was not within the 30-day requirement.
Plan of Correction:	The community will ensure that within 30 days preceding the admission, the resident will have a physical examination by an independent physician. The community will create a move in check list that determines required move in documentation and Executive Director and/or designee will review all documentation prior to the resident moving into the community.
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident?s condition, using the UAI, shall be utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 9-18-23, resident #3?s record did not include an updated uniform assessment instrument (UAI), the document in the record was dated 10-14-22. Staff #1 acknowledged the resident?s UAI was not updated. 2. Staff #1 acknowledged the resident?s
Plan of Correction:	The community will ensure that an annual reassessment and reassessment due to a significant change in the resident?s condition will be completed within Virginia regulation 22VAC40-73-440-H. Executive Director and/ or designee will create a spreadsheet, documenting updated dates of all UAI's and will check weekly to address all upcoming assessments, and update spreadsheet once completed to remain in compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 9-18-23, resident #1?s record included physical therapy documentation for strength, balance, transfer and gait training dated 8-4-23. The therapy services scheduled for twice a week for four weeks. This assessed need was not documented on the ISP completed 2-17-23. Resident?s bed was observed with a black support bar/rail. This was not addressed on the ISP. 2. Resident #2?s uniform assessment instrument (UAI) dated 9-14-23 noted walking need assessed as ?No?. The resident was observed in a wheelchair and not able to walk, this need was not documented on the ISP dated 9-14-23. Mobility need is assessed as mechanical help/supervision. The ISP did not document what supervision services was provided.
Plan of Correction:	The community will ensure that reassessment due to a significant change in the resident?s condition will be completed when the community is notified or observes a residents decline or improved condition. The Executive Director and/ or designee and management team will meet weekly to discuss potential changes in residents and will update ISP's as needed to align in the residents care.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. On 9-18-23, resident #3?s record did not include an update and/or revised ISP. The ISP in the record was dated 10-14-22. 2. Staff #1 and CS-1 acknowledged the resident?s record did not have a current ISP.
Plan of Correction:	The community will ensure that an annual reassessment and reassessment due to a significant change in the resident?s condition will be completed within Virginia regulation 22VAC40-73-450-F. Executive Director and/ or designee will create a spreadsheet, documenting updated dates of all ISP's and will check weekly to address all upcoming assessments, and update spreadsheet once completed to remain in compliance.
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the menu for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 9-18-23 during a tour of the facility, the menu for meals posted was for the week 9-10-23 to 9-16-23. The snack menu was not posted. 2. Staff #1 acknowledged the menu for meals and snack menu was not posted.
Plan of Correction:	Community will ensure the menu for meals and snacks for the current week are dated and posted in an area conspicuous to residents. Dining Director and/or designee will post meal and snack menu for current week every Sunday and will in-service staff to notify Executive Director and/or designee if they notice any discrepancies on the meal or snack menu.
Standard #:	22VAC40-73-660-A
Description:	Based on observation and staff interview, the facility failed to ensure that all medications were stored in a manner consistent with the current standards of practice. Evidence: 1. On 9-18-23 during the medication pass observation with staff #3, eye drops were observed on the nightstand of resident #3. A check of the resident?s uniform assessment instrument (UAI) dated 10-14-22 noted all medications are administered by facility staff. 2. Staff #2 acknowledged the resident?s eye drops was on the nightstand and not stored in the medication cart and resident does not self-administer medications.
Plan of Correction:	The community will ensure that all medications were stored in a manner consistent with the current standards of practice mentioned in Virginia regulation 22VAC40-73-660-A. Resident Care Coordinator and/ or designee will conduct frequent medication cart audits and will contract with pharmacy consultant to conducted biannual visits focusing on medication audits to ensure compliance.
Standard #:	22VAC40-73-710-B
Description:	Based on observation and staff interviewed, the facility failed to ensure physical restraints may only be used for a medical/orthopedic restraint for support, according to a physician?s written order and with the written consent of the resident or resident?s legal representative. Evidence: 1. On 9-18-23, a black bed/guard rail was observed on resident #1?s bed. Resident stated it was there for support when getting up in the bed. Staff #3 was asked if there was a physician?s order for the device, staff was not aware if there was or not. A check of the resident?s record did not include a physician's order. 2. Staff #1 acknowledged the facility did not have a physician?s order for the assistive device on resident #1?s bed.
Plan of Correction:	The Community will ensure that physical restraints may only be used for a medical/orthopedic restraint for support, according to a physician?s written order and with the written consent of the resident or resident?s legal representative placed in the resident?s chart. The Executive Director and/or designee will conduct daily rounds to account for residents with restraints and audit every resident with a restraint to ensure that there is a Physicians order and consent signed, or Executive will remove restraint until proper documentation is collected.
Standard #:	22VAC40-73-980-C
Description:	Based on observation and staff interviewed, the facility failed to ensure that all items in the first aid kit are present and items with expiration dates are not past their expiration date. Evidence: 1. On 9-18-23, the antiseptic ointments in the first aid kit in the nursing station and the vehicle used to transport residents was dated 07/2021. 2. Staff #2 acknowledged the antiseptic ointments were expired.
Plan of Correction:	The community will ensure that all items in the first aid kit are present and items with expiration dates are not past their expiration date. The community will create a spreadsheet and assign care manager on duty and/or designee to check first aid kit supplies and expiration dates monthly and to notify the Executive Director of any supplies out of compliance.
Standard #:	22VAC40-73-980-H
Description:	Based on observation, staff and collateral interviews, the facility failed to ensure the food supply was current. Evidence: 1. On 9-18-23 a check of the facility?s emergency food and drinking water was conducted with staff #2 and CS-2. The following items were observed with expired dates: (a) Almond milk-13 quart containers expired 6-11-23; (b) Ocean Spray pineapple juice (1 case of 24 and 12- four ounce cans- dated 9-4-23; (c) Burrito 12 inches (3 packs of 12) dated 6-29-23; (d) Horseradish Aioli (6- gallon containers dated 3-14-23); Instant Yeast (2- 16 ounce packages) dated 10-14-22 and Mustard (1- 10 ounce bottle) dated 4-29-22. Due to the volume of items and small room size, the inspectors did not continue checking the food items for expired dates. CS-2 was informed the food items should be checked as many of the items did not have dates. 2. Staff #1 and #2 acknowledged the food in the kitchen pantry area was expired and other items need to be checked.
Plan of Correction:	?Community will ensure the food supply is current per regulation: 22VAC40-73-980-H The Dining Director will conduct weekly audits to ensure the availability of a 96-hour supply of emergency food and drinking water. The community will ensure 48 hours of the supply are on site, of which the facility's rotating stock may be used and will check for expirations dates on all stock items.