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: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Ensure Menus for meals and snacks for the current week are posted and dated in an area conspicuous to residents.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal 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. 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 inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-40-B
Description:	Based on the onsite record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff # 3, hire date 06/13/22, contains a criminal history record report dated 01/25/23.
Plan of Correction:	The Executive Director or designee will complete a 100% audit of all active records to assure a current criminal history is present. Audits will be conducted every 30 days for new staff hires.
Standard #:	22VAC40-73-150-B-6
Description:	Based on observation and staff interview the facility failed to ensure a facility licensed for both residential and assisted living care may be operated by an acting administrator for no more than 150 days, or no more than 90 days if the acting administrator has not applied for licensure, from the last date of employment of the licensed administrator. Evidence: 1. On 6/27/22 an email was sent to the regional licensing office including notification of change in administrator eff. 06/25/22. The notification reported staff # 3 ?will be the administrator in training under preceptorship with staff # 6. ? 2. During the onsite visit on 01/24/23, staff #1 acknowledged he was still the acting administrator in training under the preceptorship of staff # 6. 3. Staff # 3 stated staff # 6 is on site at the facility one or two times a week.
Plan of Correction:	The ED or designee is now staff #9 . Asst ED posted staff # 9 License and department head hours in building. Asst ED has state License test on March 6th.
Standard #:	22VAC40-73-260-A
Description:	Based on the record review the facility failed to ensure each direct care staff member shall maintain certification in first aid. Evidence: 1. The record for staff #5, hire date 02/25/20, contains a first aid certification with an expiration date of 2021 and a first aid certification with a completion date of 01/24/23.
Plan of Correction:	The Clinical Director or designee will conduct an audit of 100% of current staff records to assure compliance. A routine certification course will be held at the community to maintain compliance.
Standard #:	22VAC40-73-290-B
Description:	Based on observation the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 1/25/23 @ 6:16 am the posting of the on-site person in charge at the facility listed staff # 3 as the Manager on Duty. Staff #5 acknowledged being the Manager on Duty and acknowledged staff # 3 was not on site at the facility during this time.
Plan of Correction:	The Executive Director or designee will conduct staff training on Manager on Duty responsibility and notification/postings.
Standard #:	22VAC40-73-325-B
Description:	Based on the record review the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall. Evidence: 1. Resident #5?s progress notes dated 12/16/22 and 12/20/22 document fall incidents. The record does not contain a fall risk rating completed after 12/16/22 and 12/20/22. 2. Resident # 10?s progress note dated 11/07/22 documents a day 2 follow up post fall. The record does not document that a fall risk rating was completed following a fall in November of 2022.
Plan of Correction:	The Clinical Director or designee will utilize the community QA packet to assure completion of fall risk rating after incident and/or annually.
Standard #:	22VAC40-73-410-A
Description:	Based on the record review the facility failed to ensure upon admission the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative and such documentation shall be kept in the record?s record. Evidence: 1. The record for resident # 6 does not contain documentation of completion of an orientation upon admission.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed at least annually. Evidence: 1. The record for resident #3 contains a UAI dated 12/09/21. The record does not contain an annual UAI completed after 12/09/21.
Plan of Correction:	The Clinical Director or designee will audit all current records to assure compliance and utilize internal management system to maintain compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the ISP includes a description of identified needs based upon the UAI. Evidence: 1. Resident #1?s UAI dated 10/12/22 documents mechanical & human help needs for toileting. The ISP dated 10/12/22 does not include documentation of the mechanical supports needed for toileting. 2. Resident #6?s UAI dated 01/18/23 documents mechanical help needed for eating. The ISP dated 01/18/23 does not include documentation of the mechanical supports needed for eating. 3. Resident #7?s UAI dated 03/11/22 documents mechanical help needed for eating. The ISP dated 03/11/22 does not include documentation of the mechanical supports needed for eating. 4. Resident #5?s UAI dated 07/05/22 documents a need for help due to bladder and bowel incontinence. The ISP dated 01/18/23 does not include documentation of the supports needed for bowel and bladder.
Plan of Correction:	The Clinical Director or designee will audit all current records to assure compliance and utilize internal management system to maintain compliance.
Standard #:	22VAC40-73-450-E
Description:	Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. Resident #2?s ISP dated 08/18/22 was not signed by the facility and the resident or the legal guardian. 2. Resident # 3?s ISP dated 12/09/21 was not signed by the facility and resident or the legal guardian. 3. Resident #4?s ISP dated 01/18/23 was not signed by the resident or the legal guardian. 4. Resident #5?s ISP dated 01/18/23 was not signed by the resident or the legal guardian. 5. Resident #6?s ISP dated 01/18/23 was not signed by the resident or the legal guardian. 6. Resident # 7?s ISP dated 03/11/22 was not signed by the resident or the legal guardian.
Plan of Correction:	The Clinical Director or designee will utilize all available forms of secure correspondence to obtain RP signatures as needed on ISP. All attempts to obtain signature will be noted on the ISP.
Standard #:	22VAC40-73-450-F
Description:	Based on the record review the facility failed to ensure the ISP shall be reviewed and updated at least once every 12 months. Evidence: 1, The record for resident #3 contains an ISP dated 12/09/21. There is no documentation in the record of an ISP completed after 12/09/21.
Plan of Correction:	The Clinical Director or designee will The Clinical Director or designee will audit all current records to assure compliance and utilize internal management system to maintain compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s order and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. The record for resident # 5 contains a physician order dated 01/17/23, and a medication administration record (MAR) for Dec. 2022 and Jan. 2023 that includes an order for amlodipine Besylate Tablet 10 mg ?give 1 tablet by mouth one time a day for HTN. Hold for BP less than 120.? The MAR for Dec. 2022 and Jan. 2023 documents the medication was administered on the following dates: 12/27/22, BP reading of 110/54; 12/28/22, BP reading of 116/57; 12/29/22, BP reading of 114/63; 01/04/23 BP reading of 119/59.
Plan of Correction:	The Clinical Director or designee will conduct a 100% staff inservice for current registered medication aids and Licensed Practical Nurses related to the Medication Management Plan and the Five Rights of Medication Administration. Routine audits will be conducted for compliance.
Standard #:	22VAC40-73-700-2
Description:	Based on observation the facility failed to post ?No Smoking-Oxygen In Use? signs in any room of a building where oxygen is in use. Evidence: 1. Resident #1?s room contained an oxygen tank. There was no evidence of a no smoking-oxygen use sign posted in the resident?s room or outside the resident?s door. 2. Resident #1 acknowledged use of oxygen as needed.
Plan of Correction:	The Clinical Director placed a ?no Smoking sign? during inspection. The Clinical Director or designee will audit resident orders to determine need for Oxygen signs and place signage in a timely manner.