Inspection Report
Renewal
Census: 27
Deficiencies: 11
Dec 11, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the Cambridge Landing Assisted Living & Memory Care facility to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations including lack of staff training for those in charge, volunteers not completing orientation, direct care staff not certified in first aid within required timeframe, failure to register with the Virginia Department of State Police for sex offender notifications, failure to post weekly menus conspicuously, absence of a diet manual, incomplete oversight of special diets, lack of a written emergency preparedness plan, failure to conduct semi-annual emergency preparedness reviews, missed monthly fire drills, and failure to conduct mental health emergency exercises.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure staff had training on duties and responsibilities prior to being placed in charge when manager was not on premises. |
| Facility failed to ensure all volunteers attended orientation prior to beginning volunteer service. |
| Facility failed to ensure direct care staff received first aid certification within 60 days of employment. |
| Facility failed to ensure registration with Virginia Department of State Police for sex offender notifications. |
| Facility failed to ensure weekly menu was posted in an area conspicuous to residents. |
| Facility failed to ensure a diet manual containing acceptable nutrition practices was available. |
| Facility failed to ensure oversight of special diets included a certification statement from the dietician. |
| Facility failed to develop a written emergency preparedness and response plan. |
| Facility failed to implement a semi-annual review on the emergency preparedness and response plan. |
| Facility failed to ensure monthly fire drills were completed. |
| Facility failed to ensure staff participated in exercises on handling resident mental health emergencies. |
Report Facts
Number of residents present: 27
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of resident interviews conducted: 2
Number of staff interviews conducted: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill James | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff 1 | Named in deficiencies related to training and first aid certification | |
| Staff 2 | Named in deficiency related to training and designation as person in charge | |
| Staff 8 | Confirmed issues with first aid certification and menu posting | |
| Staff 9 | Confirmed multiple deficiencies including training, emergency preparedness, fire drills, and mental health emergency exercises | |
| Staff 11 | Confirmed volunteers had not completed orientation |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Mar 27, 2024
Visit Reason
The inspection was conducted as a complaint-related investigation to review allegations or self-reports of non-compliance with standards or law.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law. Residents were observed participating in activity programs, and an exit meeting was planned to review the inspection findings.
Complaint Details
The inspection was complaint-related, but the investigation did not substantiate the allegations or self-reports of non-compliance.
Report Facts
Number of residents present: 23
Number of resident interviews: 3
Number of staff interviews: 1
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Jan 31, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-05 regarding allegations in the areas of staffing and supervision and resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint related to staffing and supervision and resident care and related services; allegations were not substantiated.
Report Facts
Number of residents present: 22
Number of staff records reviewed: 2
Number of resident records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 0
Inspection Report
Monitoring
Census: 24
Deficiencies: 0
Nov 6, 2023
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 2023-10-01 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and a copy of the most recent inspection findings is required to be posted on the facility premises.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 24
Deficiencies: 2
Nov 6, 2023
Visit Reason
The inspection was conducted as a renewal inspection to evaluate compliance with applicable standards and laws for license renewal.
Findings
The inspection found non-compliance with medication administration standards, including failure to administer medication according to physician instructions and incomplete documentation on Medication Administration Records.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's instructions for one of six residents. |
| Medication Administration Records did not include date, time given, and initials of direct care staff administering medication for one of six residents. |
Report Facts
Residents present: 24
Resident records reviewed: 6
Staff records reviewed: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 21, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-08-21 regarding allegations in the areas of resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The licensing inspector completed a tour of the facility and observed staff interactions and resident rooms. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Complaint Details
Complaint investigation related to allegations in resident care and additional requirements for adults with serious cognitive impairments; the complaint was not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 0
Inspection Report
Monitoring
Census: 23
Deficiencies: 3
Sep 21, 2023
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at Cambridge Landing Assisted Living & Memory Care.
Findings
The inspection found non-compliance with certain standards related to staff certification in first aid and medication administration documentation. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that each direct care staff member had a current certification in first aid within 60 days of employment. |
| 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. |
| Facility failed to ensure that Medication Administration Records (MARs) include the date prescribed and initials of direct care staff administering the medication. |
Report Facts
Number of residents present: 23
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
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-07-14 regarding allegations in the areas of resident care and related services, resident accommodations and related provisions, and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings, and the inspection summary will be posted publicly.
Complaint Details
Complaint received on 2023-07-14 regarding resident care, accommodations, and care for adults with serious cognitive impairments; investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Original Licensing
Census: 27
Deficiencies: 0
Jun 29, 2023
Visit Reason
Initial licensing inspection of Cambridge Landing Assisted Living & Memory Care to assess compliance with applicable standards and regulations.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspectors completed a tour of the physical plant, reviewed resident and staff records, and conducted interviews and observations.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 15
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
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