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: May 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 ISP shall specify a minimal frequency of daily rounds for residents with an inability to use the signaling device.

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 05/25/23 from 9:05 am to 4:45 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: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 8 Observations by licensing inspector: The following was reviewed: resident and staff records, medication carts, and a staffing schedule. 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 #:	22VAC40-73-640-A
Description:	Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications. Evidence 1. During the medication cart observation with staff # 2 and staff # 3 the following expired medications were observed on the medication carts located in the safe, secure unit: TUMS expired 08/2022 for resident #3; Loperamide expired 04/2023 for resident #10.
Plan of Correction:	All RMAs will conduct routine audits of their cart. The DON, ADON and charge nurses will use the Omnicare General Medication Storage Guideline and audit form to conduct weekly audits of all 5 medication carts in the community to ensure appropriate medication storage practices are being followed.
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 # 1 contains a physician order dated 01/23/23 for amlodipine Besylate Tablet 10 mg ?give 1 tablet by mouth one time a day for HTN. Hold for BP less than 120.? The Medication Administration Record (MAR) for May 2023 documents the medication was administered when the resident?s BP was less than 120 on the following dates: 05/16/23, BP reading of 112/94; 05/21/23, BP reading of 115/68 2. The record for resident #1 contains a physician order dated 01/23/23, for Carvedilol Tablet 6.25mg ?give 6.25mg by mouth two times a day for heart failure, hold for SBP less than 110 or Heart Rate (HR) less than 60.? The MAR for May 2023 documents the medication was administered when the resident?s HR was less than 60 on the following date: 05/18/23, HR reading of 54.
Plan of Correction:	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) List and review all residents with medications with parameters in QA packet and follow up accordingly.
Standard #:	22VAC40-73-680-E
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 #3 contains a physician order start date of 04/23/23 including instructions for ?clean left arm wound with DWX, apply Mepilex AG dressing to wound every 72 hours for left arm skin tear.? The resident?s MAR for April 2023, May 2023 documents the following: treatment for wound care received on 04/29/23, next 72 hours scheduled for 05/02/23 (no documentation treatment was provided), next documented treatment for wound care received on 05/05/23.
Plan of Correction:	1) Staff education sessions will be held to educate the LPN/RMA staff on the Medication/Treatment 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/Treatment Administration Observations to occur by a licensed nurse. 4)Quarterly 3rd Party Medication/Treatment Administration Observation to occur through Omnicare. 5) Run a daily (3-5 times weekly) Medication Administration/Treatment Administration Report through EHR and follow up accordingly. 6) List and review all residents receiving wound care in QA packet and follow up accordingly. 7)Annual RMA Refresher Course to be held by Omnicare.
Standard #:	22VAC40-73-930-D
Description:	Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the facility the following shall be met: 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; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years. Evidence: 1. Resident?s #2 Individualized Service Plan (ISP) dated 03/10/23 documents ?resident is unable to utilize pendant system to alert staff to their needs due to their inability to remember to use.? The resident?s record did not include documentation rounds were made for the month of May 2023. 2. Resident?s #3 ISP dated 02/18/23 documents ?resident is unable to utilize pendant system to alert staff to their needs due to their inability to remember to use.? The resident?s record did not include documentation rounds were made during the timeframe of 12:00am-5:00am on the following dates: 05/01/23, 05/03/23, 05/06/23, 05/07/23, 05/10/12, 05/12/23, 05/13/23, 05/14/23, 05/20/23, 05/22/23, 05/23/23. 3. Staff # 7 confirmed documentation of the rounds was not in the record for residents #2 and #3.
Plan of Correction:	1) Internal review of all special care unit residents ISPs will be updated with the # of checks during the day and night. RPs will be notified, and signatures will be obtained. 2) The Point of Care Audit Report will be reviewed on a weekly basis to assure the documentation is completed. Follow-up documentation will be completed within 7 days.