VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cambridge Gardens Assisted Living
9300 Onyx Court
Fredericksburg, VA 22407

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Nov. 9, 2023

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Building and Grounds Emergency Preparedness Background Checks for Assisted Living Facilities Sworn Statement

Comments:

Date of Inspection: November 9, 2023 Type of Inspection: Renewal inspection Census 39 Number of records reviewed and interviews conducted- 6 records, 4 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The LI observed residents participating in independent activity pursuits, going on a community sponsored outing and eating lunch. This Licensing Inspector also observed medication administration and compared the physician order sheets to medications available on the medication cart. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, it was determined that the facility staff failed to submit results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the Virginia Department of Health form on an annual basis. Evidence: Staff B and C did not have a current tuberculosis risk assessment in their staff file.
Plan of Correction:	Staff B and C were corrected the same day of inspection. Additional inspection of facility staff of other staff files was found and corrected immediately. Future plan is to complete risk assessments every January of all staff members regardless of the start date to ensure that the risk assessments are complete.