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: April 29, 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: Monitoring An on-site monitoring inspection IPOC was conducted on 4-29-24 (Ar 09:27 a.m./dep 15:35 p.m.) The census was 9. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

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 4-29-24, resident #1?s record did not have documentation of a psychotropic treatment plan. Resident?s admission medication listing noted resident prescribed Trazadone and Paroxetine. 2. Staff #1 and #2 acknowledged the resident?s record did not have documentation of a psychotropic treatment plan for the prescribed psychotropic medications.
Plan of Correction:	The Resident Care Coordinator and/or designee will ensure all residents on psychotropic medications upon admission has Psychopharmacologic Medication Treatment Plan in place prior to day of admission. RCC to submit all clinical admission paperwork to the Executive Director prior to new admission. Executive Director and /or designee to review weekly. 5/5/2024 ongoing for 60 days
Standard #:	22VAC40-73-450-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 4-29-24, resident #1?s uniformed assessment instrument (UAI) dated 4-14-24, bathing need assessed as mechanical help (mh). The individualized service plan (ISP) dated 4-14-24 noted bathing need as supervision. Transferring, bowel and bladder and orientation assessment is blank. The ISP noted transferring with a ?rollator, staff to assist to transfer in & out of wheelchair, bed, chair, etc.?. Bowel/Bladder noted as no assistance needed. Orientation noted as ?no?. The medication listing noted resident?s diet, ?low sodium 2gm 1500 fluid restriction diet?. This information is not on the resident?s ISP. The resident prescribed anticoagulant and goes to an outside clinic for services. The resident?s anticoagulant medication is provided by the family and not the facility?s pharmacy. This information is not documented on the resident?s ISP. 2. Staff #1 and #2 acknowledged all assessed needs of the resident were not documented on the ISP.
Plan of Correction:	The RCC/designee will ensure that reassessment due to any changes in the resident?s condition will be completed when the community observes a residents decline or improvement in condition. Executive Director and/ or designee and management team will discuss potential changes in residents daily in morning stand up and RCC/designee will update ISP's and UAI as needed after meeting to align in the residents? care. Executive Director/designee will follow up at the end of the day to ensure all necessary changes have been completed 5/5/2024 ongoing for 60 days
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. On 4-29-24, resident #2?s uniformed assessment instrument (UAI) dated 1-7-24 noted toileting need assessed as no help. The individualized service plan (ISP) noted, toileting, ?mechanical & human help/physical assistance?. Eating, bowel, bladder need is blank on the UAI. The ISP noted eating/feeding as human help/supervision. Bowel and bladder noted as incontinent less than weekly on the ISP, use of pull-up undergarment. Wheeling noted as not performed; the ISP noted ?mechanical help & human help-physical assistance, standard wheelchair?. 2. Resident #3?s UAI dated 1-7-24 noted transferring assessed as mechanical help (mh); the ISP dated 2-1-24 noted ?mechanical & human help- supervision? (mh/hh/s). Walking assessed as mh; the ISP noted walking as mh/hh/s, rollator walker. Mobility assessed as mh; the ISP noted mh/hh/s, rollator and assistance provided outside of community?. 3. Resident #4?s UAI dated 1-7-24 noted bathing as mechanical help/human help/physical assistance (mh/hh/pa). The ISP dated 2-1-24 noted mh/hh/supervision for bathing. Dressing and toileting not noted; the ISP noted dressing, use of grab bars. Toileting noted as mechanical help with use of grab bars and briefs/pullups, independent with toileting needs. 4. Staff #1 and #2 acknowledged the residents? ISP did include all assessed needs.
Plan of Correction:	This Plan of Correction is submitted as required under State law. The submission of this Plan of Correction does not constitute an admission on the part of Cambridge Crossing at Williamsburg as to the accuracy of the surveyors? findings or the conclusions drawn therefrom. The submission of this Plan of Correction does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community?s policies and procedures should be considered subsequent remedial measures, as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any judicial and/or administrative proceeding on that basis. The Community also submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies. 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 discuss potential changes in residents daily in morning stand up and RCC/designee will update ISP's and UAI as needed after meeting to align in the residents? care. Executive Director/designee will follow up at the end of the day to ensure all necessary changes have been completed 5/5/2024 ongoing for 60 days