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: June 22, 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

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 06/22/2023 from 08:06 am to 1:20 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 06/05/23, 06/06/23, 06/09/23, 06/13/23, and 06/16/23 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Safe, Secure Environment. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of lunch was completed and an observation of activities and direct care of the residents in the safe, secure unit was completed. A review of the staffing schedule was completed. 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: Safe, Secure Environment 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on the record review the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #3, contains a progress note dated 05/31/23 that documents ?observed resident lying on the floor, laceration/bleeding noted above left eye, 911 was called and resident transported to hospital for observation/evaluation.? The facility did not provide a report to the regional licensing office reporting the resident?s laceration/bleeding and transport to the hospital for observation/evaluation. 2. The record for resident #3 contains a progress note dated 06/05/23 that documents ?resident was found on the floor, ambulance was called and the resident was transported to the hospital.? The report of the incident was emailed to the Licensing Inspector from the facility on 06/26/23 which is more than 24 hours after the incident that occurred on 06/05/23.
Plan of Correction:	22VAC40-73-70-A Report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident METHODS: 1)Every time 911 or EMS is called to facility, the facility will send notification with in 24 hours to regional licensing office. The facility will follow up with Incident Report with in 7 days when applicable. Tools: 1) DSS Incident Report Executive director, Director of Clinical Services, Assistant Director of Clinical Service
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
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 #1 Individualized Service Plan (ISP) dated 06/06/2023 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: 06/07/23; 06/08/23; 06/09/23; 06/10/23; 06/11/23; 06/12/23; 06/15/23; 06/16/23; 06/18/23; 06/19/23 2. Resident?s #2 ISP dated 11/01/22 and 06/19/23 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: 06/07/23; 06/08/23; 06/09/23; 06/10/23; 06/11/23; 06/12/23; 06/15/23; 06/16/23; 06/18/23; 06/19/23; 06/20/23 3. Resident?s #3 ISP dated 04/20/23 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: 06/07/23; 06/09/23; 06/12/23; 06/14/23; 06/17/23; 06/18/23; 06/19/23; 06/20/23. 4. Resident?s #4 ISP dated 11/27/22 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: 06/08/23 and 06/16/23.
Plan of Correction:	Methods: 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 bi-weekly basis to assure the documentation is completed. Follow-up documentation will be completed within 7 days. Tools: 1) Active Resident Census report for special care unit. 2) Point of Care Audit Report. Director of Clinical Services, Assistant Director of Clinical Services