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: Jan. 24, 2023 and Jan. 25, 2023

Complaint Related: Yes

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 73 BUILDINGS AND GROUND 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 01/24/23 from 8:45 am to 4:00 pm and on 01/25/23 from 6:16 am to 1:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint) was received by VDSS Division of Licensing on (01/13/23) regarding allegations in the areas of: Staffing and Supervision and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for five residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and call bell system was monitored. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegations); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on record review the facility failed to ensure that once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours. Evidence: 1. Resident #1?s Individualized Service Plan (ISP) dated 1/18/23 documents ?resident is unable to utilize pendant system to alert staff to his needs due to inability to remember to use. Staff to check on resident every 2 hours to assess needs and safety.? There was no documentation in the resident?s record of completion of rounds every 2 hours to assess the needs and safety of the resident. 2. Resident #2?s ISP dated 1/18/23 documents ?(date initiated: 11/23/22) resident resides on memory care unit and is unable to utilize call pendant. Staff to round on resident every 2 hours to assess resident needs and safety.? 3. The record for resident #2 does not include documentation of 2-hour rounds from 12:00am to 6:00am on the following dates: 12/28/22; 12/30/22; 12/31/22; 01/03/23; 01/07/23; 01/08/23; 01/09/23; 01/12/23; 01/13/23; 01/15/23; 01/17/23; 01/18/23; 01/19/23; 01/22/23; 01/23/23. 4. Resident #3?s ISP dated 11/01/22 documents ?(dated initiated:11/07/22) resident is unable to utilize pendant system to alert staff to needs due to cognitive deficit. Staff will check on resident every 2 hours and meet identified needs and assure safety.? 5. The record for resident #3 does not include documentation of 2 hours round from 12:00am to 6:00am on the following dates: 12/28/22; 12/30/22; 12/31/22; 01/04/23; 01/07/23; 01/08/23; 01/09/23; 01/13/23; 01/15/23; 01/17/23; 01/21/23; 01/22/23; 01/23/23.
Plan of Correction:	The Clinical Director or designee will conduct all staff in-service for documentation compliance. Documentation compliance will be reviewed by the Clinical Director or designee prior to the end of each shift and addressed as needed.