Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Jun 17, 2025
Visit Reason
An unannounced non-mandated complaint inspection was conducted due to a complaint received on 2025-05-31 regarding allegations in the area of staffing and supervision and staffing for safe secure unit.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint received by VDSS Division of Licensing on 2025-05-31 regarding staffing and supervision; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 22
Number of staff interviews: 2
Inspection Report
Monitoring
Census: 22
Deficiencies: 0
May 21, 2025
Visit Reason
An on-site unannounced non-mandated monitoring inspection was conducted to review staffing, resident care, buildings and grounds, and emergency preparedness.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records, with observations including emergency food supplies.
Report Facts
Resident records reviewed: 4
Staff interviews conducted: 3
Inspection Report
Renewal
Census: 15
Deficiencies: 17
Dec 10, 2024
Visit Reason
An on-site renewal inspection was conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including staffing shortages in the special care unit, improper documentation and posting of required materials, incomplete resident records, and safety concerns such as unlocked medication storage and insufficient emergency water supply. The facility was cited for non-compliance and given opportunities to submit plans of correction.
Deficiencies (17)
| Description |
|---|
| Facility failed to ensure at least two direct care staff members were awake and on duty at all times in the special care unit. |
| Facility failed to ensure documents required to be posted were in at least 12-point type. |
| Disclosure document was not provided in advance of admission and prior to signing an admission agreement. |
| Facility written work schedule did not include names, job classification, or indication of person in charge. |
| Facility admitted or retained individuals with prohibitive conditions or care needs without proper documentation. |
| Risk assessment document did not include resident's name, date, or credentials of assessor. |
| Failed to ascertain and document if potential resident was a registered sex offender prior to admission. |
| Resident personal and social information was incomplete at admission. |
| Lack of documentation acknowledging resident orientation to the facility. |
| Uniform assessment instrument (UAI) was incomplete or missing required dates and signatures. |
| Preliminary plan of care was not signed and dated by resident or legal representative. |
| Comprehensive individualized service plan (ISP) was not completed within 30 days after admission or was incomplete. |
| Hospice care services were not included in the individualized service plan. |
| Individualized service plan was not reviewed and updated annually or as needed. |
| Menu for meals and snacks was not dated or posted in a conspicuous area. |
| Medication storage area was unlocked during inspection. |
| Food supply was not current; insufficient emergency drinking water on site. |
Report Facts
Number of residents present: 15
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of resident interviews: 4
Number of staff interviews: 6
Emergency drinking water containers: 9
Inspection Report
Monitoring
Census: 8
Deficiencies: 2
Aug 29, 2024
Visit Reason
An announced modification inspection for licensing of the safe, secure unit was conducted to review compliance with applicable standards and regulations.
Findings
The inspection found non-compliance with standards related to maintenance and cleanliness of the facility's interior and exterior, as well as inadequate supplies of toilet tissue and soap in bathrooms. Violations were documented and plans of correction were provided.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the interior and exterior of all buildings was maintained in good repair and kept clean and free of rubbish, including stained carpet, debris on outdoor furniture, and an open hole near the patio door. |
| Facility failed to ensure an adequate supply of toilet tissue and soap accessible to each commode and hand washing sink. |
Report Facts
Number of residents present: 8
Number of staff interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions related to the inspection |
Inspection Report
Monitoring
Census: 9
Deficiencies: 3
Apr 29, 2024
Visit Reason
An on-site monitoring inspection was conducted to assess compliance with applicable standards and laws at Cambridge Crossing Assisted Living.
Findings
The inspection found non-compliance with applicable standards and laws, including failure to ensure residents with prohibitive conditions were not admitted or retained, and deficiencies in individualized service plans (ISP) documentation and updates.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs; resident's record lacked documentation of a psychotropic treatment plan. |
| Facility failed to ensure the individualized service plan (ISP) included all assessed needs; resident's ISP did not document all assessed needs such as bathing, transferring, bowel/bladder, orientation, diet, and medication details. |
| Facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for significant changes in residents' conditions. |
Report Facts
Plan of Correction duration: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Inspector | Current inspector conducting the monitoring inspection |
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Renewal
Census: 13
Deficiencies: 14
Dec 18, 2023
Visit Reason
An on-site renewal inspection was conducted by two Licensing Inspectors from the Peninsula Licensing Office on December 18, 2023.
Findings
The inspection found multiple violations related to staff orientation and training, tuberculosis testing, certification listings, resident care documentation, facility maintenance, and food supply management. The facility was found non-compliant with applicable standards and laws, with documented violations requiring correction.
Deficiencies (14)
| Description |
|---|
| Failed to ensure staff orientation and training occurred within the first seven working days of employment. |
| Failed to ensure each staff person submitted tuberculosis risk assessment documentation prior to contact with residents. |
| Failed to keep an updated listing of staff with certification in first aid and CPR. |
| Failed to ensure the facility did not admit or retain individuals with prohibitive conditions or care needs without proper documentation. |
| Failed to ensure physical examination and report documents included all required information. |
| Failed to ensure annual tuberculosis risk assessment was completed for a resident. |
| Failed to ascertain and document whether a potential resident is a registered sex offender prior to admission. |
| Failed to obtain resident personal and social information prior to or at admission. |
| Failed to ensure the uniform assessment instrument (UAI) was completed and signed as required for private pay individuals. |
| Failed to develop a preliminary plan of care within seven days of admission. |
| Failed to ensure individualized service plans included all assessed needs and information. |
| Failed to have documentation of a health inspection by the Virginia Department of Health since licensing. |
| Failed to maintain the interior of the building in good repair; specifically, a damaged wall in a resident's room. |
| Failed to ensure the food supply was current; expired food items and dented cans were observed. |
Report Facts
Inspection dates: Inspection conducted on December 18, 2023 and January 19, 2024
Census: 13
Expired food items: 7
Dented can: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 3
Nov 13, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-10-04 regarding allegations of verbal abuse and building and grounds issues at Cambridge Crossing Assisted Living.
Findings
The investigation supported some, but not all, of the allegations of non-compliance. Violations were found related to admission and retention of residents with prohibitive conditions, incomplete individualized service plans, and failure to maintain furnishings and equipment in good repair, including flooding in the kitchen and dining room areas.
Complaint Details
Complaint was substantiated in part. The complaint involved allegations of verbal abuse and building and grounds issues. Evidence supported some violations related to care plans and facility maintenance.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs. |
| Facility failed to ensure the individualized service plan (ISP) included all assessed needs and information. |
| Facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair and condition, including flooding in the kitchen and dining room. |
Report Facts
Residents present: 13
Resident records reviewed: 2
Staff records reviewed: 1
Staff interviews conducted: 4
Plumber invoice date: Dec 18, 2023
Grease and solid levels: 25
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 7
Sep 27, 2023
Visit Reason
An on-site complaint inspection was conducted following a complaint received on 2023-09-25 regarding allegations in resident care, medication, and staffing at Cambridge Crossing Assisted Living.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance with standards and laws. Multiple violations were cited related to incident reporting, admission of residents with prohibitive conditions, individualized service plans, hospice care documentation, and medication administration records.
Complaint Details
Complaint was substantiated in part; evidence supported some allegations related to resident care, medication, and staffing. A violation notice was issued.
Deficiencies (7)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident affecting resident safety. |
| Facility admitted or retained individuals with prohibitive conditions or care needs without proper treatment plans. |
| Individualized service plans (ISP) did not include all assessed needs or were not updated to reflect changes. |
| Hospice care services were not included in the individualized service plan. |
| Individualized service plans were not signed and dated by required parties. |
| Individualized service plans were not reviewed and updated at least annually or as needed for significant changes. |
| Medication administration records (MAR) did not include all required information, such as staff initials for administered medications. |
Report Facts
Number of residents present: 13
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 4
Inspection Report
Monitoring
Census: 13
Deficiencies: 10
Sep 18, 2023
Visit Reason
An on-site monitoring inspection was conducted to review compliance with applicable standards and laws, including emergency preparedness, resident care, staffing, and administrative services.
Findings
The inspection found multiple violations including expired first aid certifications, physical examinations not within required timeframes, outdated resident assessments and service plans, improper medication storage, use of physical restraints without physician orders, expired first aid kit supplies, and expired emergency food items.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure direct care staff maintained current first aid certification. |
| Resident physical examination was not within 30 days preceding admission. |
| Annual reassessment and reassessment due to significant change in resident condition using UAI was not completed. |
| Individualized service plan (ISP) did not include all assessed needs. |
| ISP was not reviewed and updated at least once every 12 months or as needed for significant change. |
| Menu for meals and snacks for the current week was not dated and snack menu was not posted. |
| Medications were not stored in a manner consistent with current standards of practice. |
| Physical restraints used without physician's written order and resident/legal representative consent. |
| First aid kit contained expired antiseptic ointments. |
| Emergency food and drinking water supplies included multiple expired items. |
Report Facts
Facility census: 13
Expired antiseptic ointments date: 202107
Expired almond milk quantity: 13
Expired burrito packs: 3
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 1
Sep 18, 2023
Visit Reason
An on-site complaint inspection was conducted on September 18, 2023, following a monitoring inspection, due to a complaint received on September 11, 2023, regarding allegations in the area of staffing and supervision.
Findings
The investigation found non-compliance with staffing regulations, specifically inadequate staffing in knowledge, skills, and numbers to meet residents' needs as determined by assessments and individualized service plans. Violations were issued based on evidence including staffing schedules and staff acknowledgments.
Complaint Details
Complaint related: Yes. The complaint was substantiated as the evidence supported the allegation of non-compliance with staffing and supervision standards.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure adequate staffing in knowledge, skills, and numbers to provide services to maintain residents' physical, mental, and psychological well-being as determined by assessments and service plans. |
Report Facts
Number of residents present: 13
Number of staff interviews: 2
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 6
Sep 8, 2023
Visit Reason
An on-site complaint investigation was conducted following a complaint received on 2023-09-05 regarding allegations in staffing and supervision, resident care and related services, food, building and grounds, and management.
Findings
The investigation supported some but not all allegations, resulting in a violation notice issued for multiple deficiencies including failure to provide required disclosures, written agreements, assessments, preliminary care plans, dated snack menus, and proper grounds maintenance.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part; some allegations were supported by evidence while others were not.
Deficiencies (6)
| Description |
|---|
| Facility failed to provide a statement disclosing information about the facility to the prospective resident and legal representative. |
| Facility failed to have a written agreement/acknowledgement of notification signed by the resident or legal representative and licensee or administrator at or prior to admission. |
| Facility failed to ensure a resident was assessed face to face using the uniform assessment instrument (UAI) prior to admission. |
| Facility failed to develop a preliminary plan of care on or within seven days prior to admission to address basic resident needs. |
| Facility failed to ensure the snacks menu for the current week was dated and posted in an area conspicuous to residents. |
| Facility failed to ensure the grounds were properly maintained; tall grass and flowering were observed in the courtyard. |
Report Facts
Number of residents present: 14
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Inspection Report
Original Licensing
Census: 15
Deficiencies: 3
Jul 25, 2023
Visit Reason
An initial announced inspection was conducted to assess compliance with applicable standards and laws for licensing the assisted living facility.
Findings
The inspection found multiple violations including failure to maintain the grounds, lack of a written fire and emergency evacuation plan, and insufficient emergency food and water supplies. Plans of correction were submitted with specified completion dates.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the grounds was properly maintained to include mowing of grass. |
| Facility failed to ensure it had a written plan for fire and emergency evacuation to be followed in the event of a fire or other emergency. |
| Facility failed to ensure the availability of a 96-hours supply of emergency food and drinking water, with at least 48 hours on site at any given time. |
Report Facts
Number of residents present: 15
Plan of correction completion date: Aug 15, 2023
Plan of correction completion date: Sep 2, 2023
Plan of correction completion date: Aug 4, 2023
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