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. 23, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted by two licensing inspectors. The inspection was completed on February 23, 2022 from 9:42 a.m. to 4:30 p.m. The facility's census was 71. The complaint addressed concerns regarding resident care. Residents, staff and family members were interviewed. Based on the information obtained during the inspection the allegation was valid. The violation was reviewed during the exit interview. Information gathered during the inspection determined non-compliance with applicable standards or law, and the violation was documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-680-H
Complaint related:	Yes
Description:	Based on record review and interviews, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: 1. Medication Error Report provided by the facility dated 2/14/22 documented that Staff #2 initialed that 8:00am and 12:00pm Albuterol treatments were administered to Resident #2, however Staff #2 never administered the treatments. 2. An interview with the family of Resident #2 on 2/22/22 verified the medical treatments were not provided to the resident, as Resident #2 was not present to receive the treatments. 3. During the interview on 2/23/22, Staff #1 acknowledged that Staff #2 falsified the MAR and was terminated.
Plan of Correction:	Steps to correct the noncompliance with the standard: A full investigation was conducted. Employee was terminated. Measures to prevent noncompliance from occurring in the future: Director of Clinical Services/designee to conduct weekly medication administration observations. All staff training conducted on Five Rights of Medication Administration.