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. 16, 2021 , Feb. 23, 2021 , Feb. 24, 2021 and Feb. 25, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on February 16, 2021 and concluded on February 25, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 63. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, activities calendars, menus, staff schedules, healthcare, dietary, and pharmacy oversights, resident council notes, fire inspection, health inspection, fire and emergency drills submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-610-B
Description:	Based on record review and discussion, the facility failed to ensure menus for meals for the current week including any menu substitutions or additions were recorded on the posted menu. A record shall be kept of the menus served for two years. Evidence: 1. January and February 2021 menus were reviewed. The following items were not documented as to what was served between 01-03-2021 and 02-19-2021: Soup (du jour), fresh fruit, vegetables (du jour, medley, chef?s choice). 2. The breakfast menus were requested but not provided as documenting what was served. 3. Staff #1 confirmed any menu substitution or additions were not recorded, and the breakfast menus were not kept for January and February 2021.
Plan of Correction:	1. Executive Chef will ensure menus include specific notation of what fresh fruits, vegetables or soups are served each meal. Executive Director will review menus to ensure compliance with the standard. 2. Executive Chef will ensure breakfast menus are maintained on file for two years per the standard.