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: June 7, 2021 and June 17, 2021

Complaint Related: Yes

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 complaint inspection was initiated on June 7, 2021 and concluded on June 17, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, and the safe, secure environment of an event occurring in December 2020. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-150-C
Complaint related:	No
Description:	Based on record review and discussion, the administrator failed to be responsible for the general administration and management of the facility and shall oversee the day-to-day operation of the facility. This includes responsibility for ensuring that care is provided to residents in a manner that protects their health, safety, and well-being. Evidence: 1. Resident #1 was observed in video footage on 12-23-2020 obtained by the facility being kicked, punched, and pushed by Staff #2 and Staff #3 during an incident that began at approximately 9:34 p.m. The incident took place in the special care unit of the facility and lasted less than five minutes. 2. Staff #1 confirmed during discussion the aforementioned situation took place and Resident #1?s health, safety, and well-being was not protected in the facility.
Plan of Correction:	Measures to prevent the noncomplaince from occuring in the future: The current Executive Director will ensure care is provided to residents in a manner that protects their health, safety, and well-being. Initiated Weekly Clinical Quality Asurance Meetings, Level of Care Meetings and At Risk Meetings to consistently discuss care planning of residents. Staff will receive ongoing training as it relates to providing care for those with serious cognitive impairments. Person(s) responsible for implementation and/or monitoring preventative measures: Executive Director, Director of Clinical Services, Inspiritas Director of Clinical Services
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure when a resident suffers serious injury or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. Evidence: 1. Incident report received 12-31-2020 documented an incident that occurred on 12-23-2020 between 9:00 p.m. ? 9:30 p.m., ?Resident [#1] came into nurse?s station and was attempting to go through items. [Staff #2] came into nurse?s station and attempted to get items from resident [#1]. At that time resident [#1] swung at staff and hit [Staff #2] in the face. A private aide [Staff #4] for a resident came into the nurse?s station and put her arms around resident [#1] to prevent him from hitting at staff. At that time [Staff #2] swatted at and kicked at resident [#1]. A second staff member, [Staff #3], came and grabbed resident [#1] from nurse?s station and forced him out and pushed him from behind?? 2. Facility did not provide documentation that an assessment was completed for Resident #1 following the incident. Medical attention was not obtained for the resident following the incident. 3. Review of video footage from the 12-23-2020 incident showed Resident #1 was punched, kicked, and pushed by Staff #2 and Staff #3 as stated in the aforementioned report. 4. Staff #1 confirmed during discussion that Resident #1 was not sent out to be evaluated after the incident and medical attention was not secured immediately.
Plan of Correction:	Measures to prevent the noncompliance from occurring again: The current Executive Director re-educated staff to include the Director of Clinical Services, Inspiritas Director of Clinical Services, RN Supervisors and Charge Nurses on the standard to ensure any resident that suffers a serious injury or medical condition, or there is reason to suspect that such has occurred, receives medical attention from a licensed health care professional immediately. All staff were retrained on agreesive behaviors and redirection techniques. Staff will receive ongoing training in reference to caring for residents with serious cognitive impairments. Person(s) responsible for implementation and/or monitoring preventative measures: Executive Director , Director of Clinical Services and Inspiritas Director of Clinical Services
Standard #:	22VAC40-73-560-E
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure all resident records were kept in a locked area. Evidence: 1. Review of video footage on 06-15-2021 showed the nursing station located on the first floor of Inspiritas (Safe, Secure Environment), which contained resident records was unlocked with doors open. Resident #1 entered the area unsupervised and fumbled with papers on 12-23-2020. 2. Staff #1 confirmed the records in Inspiritas first floor were not kept secure and locked on 12-23-2020.
Plan of Correction:	Measures to prevent the noncomplaince from occuring in the future: Executive Director re-educated staff working on the Inspiritas Neighborhood of the requirement to ensure resident records are kept in a locked area. Executive Director and Inspiritas Director of Clinical Services will continue to inservice staff on the standard. Executive Director had additional keys for the nurses stations made to ensure all staff had immediate access to the keys and the nurses station doors remain locked and closed at all times. Person(s) responsible for implementation and/or monitoring preventative measures: Executive Director, Director of Clinical Services, Inspiritas Director of Clinical Services