VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bay Lake Independent, Assisted Living and Memory Care Community
4225 Shore Drive
Virginia beach, VA 23455
(757) 460-8868

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Feb. 28, 2020 and March 4, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced Renewal inspection was conducted by a Licensing Representative on February 28, 2020 from 9:13 a.m. to 4:10 p.m. and March 4, 2020 from 9:08 a.m. to 4:45 p.m. The Executive Director, Wellness Director, and Regional Director of Clinical Services were available throughout inspection on both dates. There were 64 residents in care on February 28, 2020, and 65 residents on March 4, 2020. The following was discussed during the inspection: Hazardous items left unattended, notifications of maintenance and repairs, healthcare oversight, identifying resident medications, medication administration, fire and emergency drills, admission of physical examination home health recommendations, and routine maintenance of the building. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures.

Violations:

Standard #:	22VAC40-73-680-G
Description:	Based on observation and interview, the facility failed to ensure that over-the-counter medications remain in the original container, labeled with the resident's name, or in a pharmacy-issued container, until administered. Evidence: 1. During a review of the second floor medication cart in assisted living on 02-28-20, the following medications were observed unlabeled without the resident?s name: a. GentleLAX (Polyethylene Glycol 3350), identified by staff #2 as belonging to resident #3. b. Miralax (Polyethylene Glycol 3350), belonging to unknown resident by staff #2, and c. Stool softener laxative. 2. Staff #1 acknowledged the aforementioned over-the-counter medications were not labeled with the resident?s name or in a pharmacy-issued container.
Plan of Correction:	1. Label GentleLAX with resident's name. 2. Removed Miralax and stool softener from medication cart. 3. Wellness Director audits medication carts monthly. 4. Omnicare representative will continue to complete quarterly audits on medication carts. 5. Staff will be inserviced by Wellness Director on proper labeling of medications.
Standard #:	22VAC40-73-710-B
Description:	Based on observation, record review, and interview, the facility failed to ensure whenever physical restraints are used, the facility shall closely monitor the condition of a resident with a restraint, which includes checking on the resident at least every 30 minutes. Evidence: 1. On 03-04-20 in ?Inspiritas? Special Care Unit (SCU), resident #1?s bed was observed to contain a half side rail that was in the upwards position on the right side of the bed, with the left half side rail downwards as the bed was pushed up against the wall on the left side. 2. Resident?s Individualized Service Plan (ISP) dated 01-20-20 documented resident #1?s half side rails were used for transferring and positioning. 3. ?Progress Notes? documented on 11-23-19 at 9:18 a.m. and 12-10-19 at 4:45 a.m. documented the right half side rail was up. 4. Resident #1?s record did not include checks of the resident every 30 minutes when the rails were in use. 5. Staff #1 acknowledged 30 minute checks were not documented in the resident?s record.
Plan of Correction:	1. All Inspiritas residents will be assessed for necessity and ability to properly use side rails. 2. Side rails will be removed if not appropriate at this time. 3. Orders will be reviewed to ensure they clearly outline the need of side rails, new orders will be obtained if necessary. 4. Staff on all shifts will be educated on the use of side rails and that they must be down except per order, i.e. transfers, positioning. 5. ISP will be reviewed and updated to reflect side rail usage. 6. If at any time resident is unable to properly use side rail or it is to stay up, a restraint assessment will be completed, orders and ISP updated and 30 minute checks initiated.