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 23, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 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 03/23/2023 from 08:47am to 12:26pm. 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 03/20/2023 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: 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation was completed of an office area located on the 2nd floor. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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 #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on the record review the facility failed to ensure medications shall be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except for those drugs that are ordered for specific times. Evidence: 1. The facility?s Medication Management & Services Policy documents ?medication pass times in the community are 0600/0900/1300/1700/1900.? Resident #2?s Medication Administration Record (MAR) for April and October 2022 documents a medication administration time of 9:00 am for Revlimid Capsule 20 mg. The facility?s medication administration audit report documents the resident was administered Revlimid Capsule 20mg an hour after 9:00 am on the following dates and times: 04/05/22 at 11:20 am 04/06/22 at 11:34 am 04/08/22 at 11:47 am 10/02/22 at 10:52 am 10/03/22 at 10:57 am 10/06/22 at 12:08 pm 10/08/22 at 11:09 am 10/10/22 at 10:49 am 10/11/22 at 10:11 am 10/12/22 at 10:09 am 10/14/22 at 10:51 am 10/15/22 at 11:42 am 10/16/22 at 12:43 pm 10/17/23 at 10:29 am 10/18/22 at 11:28 am 10/21/22 at 11:29 am
Plan of Correction:	Methods: 1) Staff education sessions will be held to educate the LPN/RMA staff on the Medication Administration Policies. Re-education will be held annually. 2) Biannual Health Care Oversight will be conducted to assure adherence to the policy. 3)Monthly Medication Administration Observations. 4)Quarterly 3rd Party Medication Administration Observation to occur through Omnicare. 5)Run a daily (3-5 times weekly) Medication Administration Report through EHR and follow up accordingly. 6)Annual RMA Refresher Course to be held by Omnicare. Tools: 1) Nursing P&P Manual- Medication Management and Services. 2) HealthCare Oversight Form. 3) Staff Inservice form 4) Medication Pass Observation Worksheet ? Appendix F Persons Responsible: Acting Director of Clinical Services, Assistant Director of Clinical Services RN Acting Director of Clinical Services, Assistant Director of Clinical Service, LPN Omnicare Representative Acting Director of Clinical Services, Assistant Director of Clinical Services Omnicare Representative