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: Oct. 13, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 10/13/2022 from 9:29 am until 12:57 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (self-reported incident) was received by VDSS Division of Licensing on (09/26/2022) regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. The following were reviewed: emergency preparedness and resident emergency drills; policy & procedure re: missing resident. Additional Comments/Discussion: Staff # 3 was interviewed via phone on 10/20/2022 due to the staff not being present at the facility during the on-site inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the (self-report) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (self-report) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on the record review, the facility failed to ensure the ISP shall be signed and dated by the resident or the legal guardian. Evidence: 1. In the record for resident #1, the ISP dated 02/25/22 did not include a documented signature of the resident or legal guardian.
Plan of Correction:	All active resident charts will be reviewed for compliance with obtaining a signature by the resident or legal guardian and corrected as needed. Education will be provided to certified staff on policy and procedure related to signature attainment.
Standard #:	22VAC40-73-460-D
Description:	Based on staff interview and the onsite record review the facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs. Evidence: 1. The facility reported resident #1 went missing while on a facility outing in the community. The Incident report dated 09/30/22 states ?resident was unable to be located while at an event with Bay Lake Staff.? 2. Staff #1, #2, and # 3 acknowledged resident was missing approximately 30 minutes and located by event police. 2. Resident #1 progress notes by the nurse practitioner dated 05/10/22 and 08/23/22 document a presenting problem and medical history of dementia. 3. Resident #1?s Individualized Service Plan (ISP) dated 02/25/22 documents interventions to include ?Utilize Project Lifesaver? and ?family wants resident to be able to walk with a caregiver or with a staff member.?
Plan of Correction:	The community provided education to staff related to the resident's Individualized Service Plan regarding special needs/supervision with mobility. The resident will have constant supervision for all events attended outside of the community.