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. 23, 2024 and Jan. 24, 2024

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

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 01/23/24 from 8:15 am to 3:44 pm and on 01/24/24 from 8:15 am to 2:00 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: 66 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 interviews conducted with residents: 3 Number of staff records reviewed: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for four 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 #:	22VAC40-73-450-A
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. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission. Evidence: 1. The record for resident #1, admission date of 01/30/23. does not contain a preliminary plan of care completed on or within 7 days of admission. 2. The record for resident #1 contains ISPs signed and dated by the facility on 03/03/23 and 05/16/23. The dates of the identified needs on the ISPs are documented as 02/10/23 and 04/26/23. The record for resident #1 did not contain an ISP completed on admission. During the onsite inspection the Licensing Inspector (LI) requested an ISP completed on admission for resident #1, and the ISP provided by staff #5 was signed and dated by the facility on 03/03/23.
Plan of Correction:	Plan of Correction: In respect to the specific resident/situation cited: The preliminary plan of care was not in place prior to move-in. A comprehensive plan of care for resident #1 will be reviewed at least annually and as needed. With respect to what systemic measures have been put into place to address the stated concern: The Director of Clinical Services/designee will work with the administrator/designee to ensure that preliminary plans of care are in place prior to or on the day of move-in.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, resident and staff interviews, and the record review the facility failed to ensure the facility shall implement a written plan for medication management to include methods to prevent the use of outdated, damaged, or contaminated medications; methods to ensure that each resident?s prescription medications and any over the counter drugs and supplements ordered for the resident are filled and re-filled in a timely manner to avoid missed dosages. Evidence: 1. The facility?s medication management plan includes the following: ?the community should destroy all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with destruction guidelines.? During the medication cart observation with staff #6 the following expired medication was located on the cart: Clindamycin Phosphate prescribed to resident #10, expired 11/2023.
Plan of Correction:	Plan of Correction: In respect to the specific resident/situation cited: Resident #10?s Clindamycin Phosphate has been removed from the cart and disposed of properly. In respect to how the facility will identify resident/situations with the potential for the identified concerns: Staff licensed to administer medications will be educated on the medication management plan and compliance audit tools. Medication carts will be audited regularly by staff licensed to administer medications to ensure compliance. With respect to what systemic measures have been put into place to address the stated concern: Our pharmacy, Omnicare, provides medication cart audits on a bi-annual and as needed basis to ensure practices are upheld and in compliance with our medication management plan. Omnicare also provides in-services for our licensed employees who administer medications.
Standard #:	22VAC40-73-680-D
Description:	Based on the record review, and interviews, the facility to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1.The record for resident #3 contains a physician order dated 07/26/23 for Lumigan Solution 0.01%, instill 1 drop in both eyes at bedtime. On 01/23/24, during the medication pass observation with staff #1, resident #3 informed staff #3 the resident has not been administered Lumigan Solution within the last 3 days. Staff #1 confirmed the Lumigan Solution prescribed to resident #3 was not on the medication cart and was not located in the facility. 2. Resident?s #3 Medication Administration Record (MAR) for Jan. 2024 does not include documentation the resident was administered, Lumigan Solution eye drops, at bedtime for the dates of 01/18/24 through 01/21/24.
Plan of Correction:	Plan of Correction: In respect to the specific resident/situation cited: Resident #3?s Lumigan Solution is on the cart and being administered to the resident following physician orders. In respect to how the facility will identify resident/situations with the potential for the identified concerns: Director of Clinical services/designee will monitor the electronic Medication Administration Record to identify potential areas of concern regularly. Staff will also be educated on the medication reordering process. With respect to what systemic measures have been put into place to address the stated concern: Staff licensed to administer medications will be educated on the medication management plan and compliance audit tools. Medication carts will be audited regularly by staff licensed to administer medications to ensure compliance
Standard #:	22VAC40-73-680-M
Description:	Based on observation the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. During the medication cart review with staff #6 the following medication was located on the cart and was not labeled with the resident?s name: Cran RX, Bioactive Cranberry. Staff #6 confirmed the Cran RX was not labeled with a resident?s name and stated the medication belonged to resident #6.
Plan of Correction:	Plan of Correction: In respect to the specific resident/situation cited: Resident #6?s Cran RX has been properly labeled with the resident?s name. With respect to what systemic measures have been put into place to address the stated concern: Ensure labels are available for staff to use for over-the-counter medications and educate the staff on how to properly label a medication. Staff licensed to administer medications will be educated on the medication management plan and compliance audit tools. Medication carts will be audited regularly by staff licensed to administer medications to ensure compliance.