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: Dec. 18, 2023 and Jan. 19, 2024

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 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal An on-site renewal inspection conducted by two LI from the Peninsula Licensing Office on 12-18-23. The census was 13. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure staff orientation and training required bin subsections 120-B and 120-C occurred within the first seven working days of employment. Evidence: 1. On 12-18-23, staff #5?s orientation document in the record was blank, no signatures and no dates noted. 2. Staff #2 acknowledged the staff?s orientation document was not completed.
Plan of Correction:	Executive director, Resident Care Coordinator and/or designee to complete staff orientation within the first seven days of employment. Quarterly audit to be completed to ensure regulatory compliance 2/12/2024 ongoing for 6 months
Standard #:	22VAC40-73-250-D
Description:	Based on record reviewed, document reviewed, and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results or a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form. Evidence: 1. On 12-18-23, staff #5?s TB testing was dated 11-17-23, the staff?s date of hire noted as 11-13-23. The document was completed by staff #2, who did not have the credentials to complete the document. 2. Staff #1 did not have documentation of a TB testing. Staff effective date as interim administrator noted as 9-22-23. 3. Staff #1 acknowledged staff members TB was not in accordance with the regulation.
Plan of Correction:	Executive Director, Resident Care coordinator and/or designee to Send all staff for Tuberculosis testing upon hire, unless nurse present in building. Executive Director, Resident Care coordinator and/or designee to complete Quarterly audit to be completed to ensure regulatory compliance 2/12/2024 audit ongoing for 6 months
Standard #:	22VAC40-73-260-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the listing of all staff who have certification in first aide and or CPR was kept up to date. Evidence: 1. On 12-18-23 during the medication pass observation, the first aid and CPR certification listing posted in the medication room was observed to not be updated. Staff #3?s document expired 11-22-23 and staff #7?s document expired 11-22-2023. Staff #5?s name was not on the posted listing. Staff #5?s First aid and CPR document in the record had an expiration date of 8-2023. 2. Staff #2 acknowledged the first aid and CPR listing was not kept updated.
Plan of Correction:	Executive Director, Resident Care coordinator and/or designee to ensure all staff have certification in first aide and or CPR up to date. Executive director, Resident care coordinator and/or designee to complete quarterly audits to maintain regulatory compliance. 2/12/2024 ongoing for 6 months
Standard #:	22VAC40-73-310-H
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure it did not admit retain individuals with a prohibitive conditions or care needs. Evidence: 1. On 12-18-23, resident #1?s record included documentation for Seroquel. The record did not include a treatment plan for this psychotropic medication. 2. Staff acknowledged the resident?s record did not have documentation of a psychotropic treatment plan for the prescribed Seroquel.
Plan of Correction:	The Resident Care Coordinator and/or designee will ensure all residents on psychotropic medications will have a Psychopharmacologic Medication Treatment Plan in place when medication is prescribed and/or discontinued and will be reviewed monthly by Executive Director and /or designee. 2/12/2024 Corrected and ongoing for 6 months
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the physical examination and report document included all required information. Evidence: 1. On 12-18-23, resident #1?s physical examination was completed after resident?s 11-30-23 admit date; the document was dated 12-1-23. The physical examination document did not include the resident?s height, weight, and blood pressure. 2. Resident #1?s risk assessment documenting the absence of tuberculosis (TB) form did not include the resident?s name nor the credentials of the person completing the assessment. The document was signed dated 12-1-23 after the resident?s admission date of 11-30-23. Another TB document was dated 12-2-23, but it did not include the name, date, and signature of the evaluator.
Plan of Correction:	Resident Care Coordinator and/or designee to work with Physician to ensure all Physical examinations/report documents include all required information. Executive Director and /or designee to complete quarterly audits to ensure regulatory compliance. 2/12/2024 Audit ongoing for 6 months
Standard #:	22VAC40-73-320-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident. Evidence: 1. On 12-18-23, resident #3?s record did not include an updated annual TB risk assessment. The document in the record was dated October 2022. The resident?s date of admit noted as 9-18-21.
Plan of Correction:	Resident care coordinator and/or designee to ensure risk assessment for tuberculosis is completed for each resident annually. Executive directive and/or designee to complete quarterly audit to ensure regulatory compliance 2/12/2024 audit ongoing for 6 months
Standard #:	22VAC40-73-350-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it ascertain, prior to admission, whether a potential resident is a registered sex offender, if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident?s record that this was ascertain and the date the information was obtained. Evidence: 1. On 12-18-23, resident #1?s sex offender documentation was dated 12-5-23. The resident?s date of admission was dated 11-30-23. 2. Staff acknowledged the sex offender document for resident #1 was not obtained prior to admission.
Plan of Correction:	Executive Director and /or designee to ensure, prior to admission, whether a potential resident is a registered sex offender. Quarterly audit to be completed to ensure regulatory compliance. 2/12/2024 ongoing for 6 months
Standard #:	22VAC40-73-380-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to or at the time of admission to the assisted living facility, resident?s personal and social information on a person shall be obtained. Evidence: 1. On 12-18-23, resident #1?s personal and social data information section was blank for the following personal data: date of admission, special interest and hobbies, lifetime vocation-career or primary role; and information concerning advance directives, if applicable. The resident?s allergies were not documented; resident?s active medication document dated 12-4-23 noted the following allergies: Statins- HMG-COA Reductase Inhibitors; Clarithromycin, Cephalosporins, Erythromycin Base, Sulfa (Sulfonamide antibiotics), Ioversol, Egg and Dye. 2. Staff acknowledged the resident?s social data information document was incomplete.
Plan of Correction:	Executive Director, Resident Care coordinator and/or designee to ensure all resident personal and social information be collected prior to or at time of admission. Executive director, Resident care coordinator and/or designee to complete quarterly audits to maintain regulatory compliance. 2/12/2024 audit ongoing for 6 months
Standard #:	22VAC40-73-440-D
Description:	Based on record reviewed and staff interviewed, the facility to ensure for a private pay individual, the uniform assessment instrument (UAI) was completed as required. Evidence: 1. On 12-18-23, resident #1?s UAI dated 12-1-23 was completed by staff #2, however, the document was not signed and dated by the administrator or designee. 2. Resident #2?s UAI completed by staff #2 was not signed and dated by the administrator or designee, 3. Staff #2 acknowledged the residents? UAIs were only signed by one-person, and there was not an administrator or designee from the facility?s signature and date.
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 observes a residents decline or improvement in condition. The Executive Director and/ or designee and management team will meet weekly to discuss potential changes in residents and will update ISP's and UAI as needed to align in the residents? care. 2/12/2024 audit ongoing for 6 months
Standard #:	22VAC40-73-450-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects the resident?s health, safety, and welfare. Evidence: 1. On 12-18-23, resident #1?s record did not have documentation of an individualized service plan (ISP). There was no preliminary, neither a comprehensive care plan in the resident?s record. 2. Staff #1 and #2 acknowledged the resident?s record did not have a plan of care.
Plan of Correction:	Executive Director, Resident Care coordinator and/or designee to ensure a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects the residents? health, safety, and welfare. prior to or within seven days of admission. Executive director, Resident care coordinator and/or designee to complete quarterly audits to maintain regulatory compliance. 2/12/2024 audit ongoing for 6 months
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the individualized service plan (ISP) included all assessed needs and information. Evidence: 1. On 12-18-23, resident #2?s ISP dated 11-21-23 did not include the assessed need date and outcome dates. 2. Resident #3?s ISP dated 10-19-23 did not include the assessed need date and outcome dates. The resident?s therapy services were not documented on the ISP. Occupational therapy services in record were dated 10-16-23, 10-18-23, 10-24-23, 10-26-23, 11-2-23 and11-6-23 Physical therapy services dated 10-25-23 and 10-27-23. 3. Staff acknowledged the residents? ISP did not include all assessed needs and required information.
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 observes a residents decline or improvement in condition. The Executive Director and/ or designee and management team will meet weekly to discuss potential changes in residents and will update ISP's and UAI as needed to align in the residents? care. 2/12/2024 audit ongoing for 6 months
Standard #:	22VAC40-73-580-A
Description:	Based on interviews, the facility failed to ensure when any portion of the facility was subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual report from the Virginia Department of Health. Evidence: 1. On 12-18-23, the facility did not have documentation of a health inspection since receiving its license, 7-25-23. The kitchen?s last inspection date from the health department was 11-10-22. 2. Upon contacting the health department, the facility had submitted an application for a license and inspection on 12-15-23.
Plan of Correction:	Maintenance and/or designee to ensure all inspections required by the Virginia Department of Health. Quarterly audit to be completed by Executive Director and/or designee to be completed to ensure regulatory compliance. 2/12/2024 audit ongoing for 6 months
Standard #:	22VAC40-73-870-A
Description:	Based on observation the facility failed to ensure the interior of the building was maintained in good repair. Evidence: 1. On 12-18-23 during a tour and medication pass observation with staff #5, the wall in resident #2?s room was observed to be damaged, with a hole behind the resident?s lounge chair. 2. Staff #1 did not have documentation of a service request for repair and not aware of when or how long the wall was in need of repair. 3. Staff #5 acknowledged the wall in room #302- resident #2 was damaged.
Plan of Correction:	Maintenance Director and/or designee to ensure service request be completed and issue fixed in a timely manner. Quarterly audit to be completed by Executive Director and/ or designee to ensure regulatory compliance 2/12/2024 Corrected ongoing for 6 months
Standard #:	22VAC40-73-980-H
Description:	Based on observation, staff interviewed, the facility failed to ensure the food supply was current. Evidence: 1. On 12-18-23 during a tour of the kitchen, the current food mixed with 96-hour emergency food supply was observed to have expired food items. Jamaican Jerk-wing sauce (2- 64 oz bottles- 11-19-23 expired date) Mango Habanero wing sauce (5- 64 oz bottles- 10-19-23 expired date). A dented tomato puree (6 lbs. 9 oz can). 2. Staff #1 acknowledged the expired items and dented can in the food pantry on 12-18-23.
Plan of Correction:	Kitchen vendor to ensure food supply is current. Executive director and/or designee to complete quarterly audit to ensure regulatory compliance 2/12/2024 Audit ongoing for 6 months