VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cambridge Landing Assisted Living & Memory Care
304 Bowman Mill Road
Strasburg, VA 22657
(540) 465-5900

Current Inspector: Jill James (540) 418-2631

Inspection Date: Sept. 21, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 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 LICENSE 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:43 am on 9/21/2023 and exited at 3:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 23 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and engaging in activities. Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based upon a review of records during a mandated inspection conducted on 9/21/2023, the facility failed to ensure that each direct care staff member had a current certification in first aid within 60 days of employment. Evidence: 1. The staff record for Staff #3, who was hired on 7/15/2023, did not contain a current certification in first aid.
Plan of Correction:	Staff #3 has completed First Aid training on 9/21/2023. All staff files have been audited to ensure compliance. Training log sheets will be kept updated and current to track training needs.
Standard #:	22VAC40-73-640-A
Description:	Based upon a review of records, the facility failed to ensure that medication orders were transcribed to Medication Administration Record (MAR) within 24 hours of receipt of a new order or change in an order. Evidence: 1. The record for Resident #1 contained a physician's order to discontinue Furosemide 20mg on 8/16/2023. 2. The discontinued order for Furosemide 20mg was listed on the September 2023 MAR for Resident #1.
Plan of Correction:	Nurse will audit all orders received in the EMAR system for accuracy. The audits will take place daily as orders are received by the physician.
Standard #:	22VAC40-73-680-I
Description:	Based upon a review of records and observations, the facility failed to ensure that Medication Administration Records (MARs) include the date prescribed and initials of direct care staff administering the medication. Evidence: 1. The September 2023 MAR for Resident #2 (R2) did not include the date the following medications were prescribed: Risperidone, Probiotic, and Cipro. 2. The September 2023 MAR for Resident #1(R1) did not include the date Furosemide 40mg was prescribed. 3. Licensing Inspector (LI) observed Staff #1 administer medications to R1 at approximately 9:25 am on 9/21/2023 and to R2 on 9/21/2023 at approximately 9:45 am. 4. LI reviewed September 2023 MARS for R1 and R2 and observed that Staff #1 did not initial the MARs for 9/21/2023 for the medication administered to R1 at approximately 9:25 am and to R2 at approximately 9:45 am. 5. The September 2023 MAR for Resident #5 did not have initials of direct care staff who administered medications at approximately 8:00 am on 9/2/2023.
Plan of Correction:	Facility will be live with new electronic medication administration system (EMAR) and all medication aids will be trained on using the new system by 10/10/2023. Nurse will check medication orders for accuracy prior to initial use of EMAR system. All staff will receive an in-service on proper documentation. To include the 5 rights of medication administration and signing off administered medication. Nurse audited all paper MARS for accuracy. Nurse will audit all medication orders to ensure accuracy on all orders in the electronic system.