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: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site complaint inspection was conducted on 9-18-23 following a monitoring inspection (3:45 p.m. 5:05) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9-11-23 regarding allegations in the area of staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 13 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 2 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 the complaint 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 (Willie Barnes), Licensing Inspector at (757)-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure it had staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychological well-being of each resident as determined by the resident assessments and individualized service plans, and to ensure that compliance with the regulations. Evidence: 1. On 9-18-23, during a complaint inspection regarding allegation of one staff on the 3 to 11 p.m. shift, the staffing scheduled provided noted one direct care staff scheduled. On 9-1-23, the schedule noted one, staff (registered medication aide (RMA) worked from 7:00 a.m. to 7:00 p.m. On 9-2-23, one RMA worked from 7:00 a.m. to 3:00 p.m. On 9-4-23, one RMA worked from 7:00 p.m. to 11:00 p.m. On 9-2-23 one RMA worked from 7:00 p.m. to 11:00 p.m. 2. The facility has residents in the facility assessed as two -person assist, assistance with bathing, dressing, feeding, wheeling, mobility, incontinent care and transferring. The facility has residents who are assessed with cognitive impairments and resident who wanders. 3. Staff #1 acknowledged the facility did not have sufficient staff scheduled on the aforementioned dates.
Plan of Correction:	? Community will ensure adequate staffing in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychological well-being of each resident as determined by the resident assessments and individualized service plans, and to ensure that compliance with the regulations. Community will utilize scheduling app that allows for updates and notifies management of live staffing needs of the community. Executive Director and/ or designee will ensure coverage for every shift and will be available 24/7 to address any staffing concerns. Staff will be Inservice on safe staffing ratios, shift change, call out policy, and will be given the numbers of management on site to address any upcoming staffing issues before the shift starts.