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: March 3, 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 22VAC40-73 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 03/03/2023 from 8:24 am to 11:52 am. 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 (01/18/23) 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: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of interviews conducted with residents: 0 Number of staff record reviewed: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of the safe, secure unit was completed. Additional Comments/Discussion: None 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 #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: 1. The record for resident #1 does not contain a preliminary plan of care or an individualized service plan (ISP) completed on or prior to the resident?s admission date of 02/01/23. The ISP in the record documents an initiated date of 2/10/23.
Plan of Correction:	DON or designee will update POA on ISP with notation as soon as possible within 24 hours of modification DON or designee will develop comprehensive ISP prior to physical move in of all new residents DON or designee will audit ISP of all new residents the day before the actual day of physical move in to ensure correct dates and signatures 100% chart Audit for signatures by 3/30/23
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions 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 #3 contains a physician order dated 02/15/23 for medication administration of Doxycycline ?One tablet by mouth two times a day for left arm abrasion infection for 7 days.? The resident?s Medication Administration Record (MAR) for Feb. 2023 documents the medication was first administered on 02/16/23. The MAR and the resident?s progress notes did not include documentation the resident was administered Doxycycline two times a day on the 7th day, which was 02/22/23.
Plan of Correction:	Educate staff that all antibiotic orders will be entered into PCC using the duration of administration option to assure all doses are administered according to physician order Will routinely track antibiotics moving forward on weekly QA packet ALL Nursing Staff Inservice-3/15/23 ALL Staff Meeting- 3/29/23 (Nursing Inservice after for any not present 3/15/23)
Standard #:	22VAC40-73-680-E
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident?s record. Evidence: 1.The record for resident #2 contains a physician order dated 02/24/23 including instructions for ?daily wound care order for skin tear on right elbow.? The resident?s (MAR) for Feb. 2023 and the resident?s progress notes did not include documentation the resident received wound care on the date of 02/26/2023.
Plan of Correction:	Educate staff on order start dates based on needs of the order Educate that a MAR/TAR triggered in red needs to be addressed with a progress note ALL Nursing Staff Inservice-3/15/23 ALL Staff Meeting- 3/29/23 (Nursing Inservice after for any not present 3/15/23)