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: Nov. 13, 2023 , Dec. 18, 2023 and Jan. 19, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site complaint was conducted on 11-13-23 (AR 09:05/ Dep 17:00). The census was 13. 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 10-04-23 regarding allegations in the area of verbal abuse and building and grounds. 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: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: Number of interviews conducted with staff: 4 Observations by licensing inspector: most residents have cognitive impairment Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were valid. A violation notice was 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 #:	22VAC40-73-310-H
Complaint related:	No
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 11-13-23, resident #1?s record noted a physician?s order dated 10-16-23 and 10-25-23 to discontinue Lorazepam and start Vistaril and physician?s order dated 11-8-23 for Sertraline. The resident?s record did not have documentation of a treatment plan for the psychotropic medications. 2. Staff #1 and #2 acknowledged the resident?s record did not include a treatment plan for the psychotropic medications.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs and information. Evidence: 1. On 11-13-23, in response to a complaint of staff verbally abusing a resident with cognitive impairment a review of resident#1?s record was conducted. Resident #1?s uniformed assessment instrument (UAI) dated 10-19-23 documented transferring need assessed as mechanical help/supervision. The ISP signed 10-19-23 did not document what supervision was needed. Walking need assessed as human help/supervision. The ISP documented walking need with or without mechanical device. Behavior assessed as appropriate, the ISP documented resident as ?abusive, aggressive, disruptive with yelling at staff and residents and refusing adl assistance?. 2. The resident?s ISP did not include the need date and did not include the outcome date for needs documented on the care plan. 3. Staff #1 acknowledged the resident?s individualized care plan did not include assessed needs. Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs and information. Evidence: 1. On 11-13-23, in response to a complaint of staff verbally abusing a resident with cognitive impairment a review of resident#1?s record was conducted. Resident #1?s uniformed assessment instrument (UAI) dated 10-19-23 documented transferring need assessed as mechanical help/supervision. The ISP signed 10-19-23 did not document what supervision was needed. Walking need assessed as human help/supervision. The ISP documented walking need with or without mechanical device. Behavior assessed as appropriate, the ISP documented resident as ?abusive, aggressive, disruptive with yelling at staff and residents and refusing adl assistance?. 2. The resident?s ISP did not include the need date and did not include the outcome date for needs documented on the care plan. 3. Staff #1 acknowledged the resident?s individualized care plan did not include assessed needs. Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs and information. Evidence: 1. On 11-13-23, in response to a complaint of staff verbally abusing a resident with cognitive impairment a review of resident#1?s record was conducted. Resident #1?s uniformed assessment instrument (UAI) dated 10-19-23 documented transferring need assessed as mechanical help/supervision. The ISP signed 10-19-23 did not document what supervision was needed. Walking need assessed as human help/supervision. The ISP documented walking need with or without mechanical device. Behavior assessed as appropriate, the ISP documented resident as ?abusive, aggressive, disruptive with yelling at staff and residents and refusing adl assistance?. 2. The resident?s ISP did not include the need date and did not include the outcome date for needs documented on the care plan. 3. Staff #1 acknowledged the resident?s individualized care plan did not include assessed needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Complaint related:	Yes
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment shall be kept clean and in good repair and condition. Evidence: 1.On 11-13-23, in response to a complaint regarding flooding in the building, the inspector toured the kitchen and dining room area with staff #1 and #4. Staff #4 acknowledged the facility?s kitchen flooded in October 2023 and a section of the dining room did get wet. Staff #4 stated that the grease trap in the kitchen backup causing flooding in the kitchen. A section of the carpeted area from the dining room located near the entrance to the kitchen was wet from the kitchen flood. 2. A copy of the plumber?s invoice noting the cleaning of the grease trap was provided to the inspector on 12-18-23. ?The measurements taken at this location, the grease and solid levels were above the 25% rate?The plumbing recommends that the grease trap at this location be serviced more often?. 3. Staff #4 acknowledged the flooding in the kitchen traveled into the dining room and DSS was not notified of the flood involving the kitchen and dining room area.
Plan of Correction:	Not available online. Contact Inspector for more information.