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: Lanesha Allen (757) 715-1499

Inspection Date: Sept. 21, 2020 and Sept. 22, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on September 17, 2020 and concluded on September 22,2020. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 65. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 4 resident records, weapons policy, nursing notes, other staff communication, and resident personal belongings policy submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1180-B
Description:	Based on record review and discussion, when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. Resident #1?s Individualized Service Plan dated 09-03-2020 documented, ?Behavior ? Aggressive, Abusive, Disruptive, Agitated?. 2. Resident #1?s Progress Notes dated 08-29-2020 18:54 documented, ?Note Text: Staff reported [resident #1] became very agitated and was exit seeking. Went up on the elevator to 2nd floor where we got a hold of a wooden stick and hit staff on the top of head. Went into another resident?s room and got a hold of a wine bottle opener and was threatening staff with it?? 3. Staff #1 confirmed resident #1 had obtained an ordinary object that may be harmful to a resident.
Plan of Correction:	Executive Director will be conducting a mandatory all staff meeting on ordinary objects or materials that may be harmful to residents. A full inspection of each resident?s apartment on Inspiritas to be conducted by Executive Director, Wellness Director and Assistant Wellness Director to ensure any potential harmful materials or objects are removed.
Standard #:	22VAC40-73-860-K
Description:	Based on record review and discussion, the facility failed to implement a written policy regarding weapons on the premises of the facility that will ensure the safety and well-being of all residents and staff. Evidence: 1. Resident #1 moved into the Safe Secure Environment (SSE) on 08-03-2020. Resident #1?s Uniform Assessment Instrument (UAI) dated 09-01-2020 documented the resident as Abusive/Aggressive/Disruptive, Weekly or More. 2. An initial incident report received by the regional licensing office on 08-17-2020 documented, ??We had [resident #1] who in the last week moved had onto the unit from our Assisted Living side come into possession of a type of Swiss army knife. [Resident #1] was agitated and exit seeking and tapping the knife on our exit door and asking staff to let [resident #1] out. Staff attempted to -re-direct and secure item but resident [#1] would not give the item to staff?? 3. The following Progress Notes documented Resident #1?s behaviors: A. 08-03-2020 21:58 documented, ?Note Text: patient [Resident #1] moved to 107 On inspiritous did well until day went tonight [resident #1] became more agitated trying to get out??, B. 08-04-2020 21:48 documented, ?Note Text: Resident [#1] was given Ativan for agitation this shift??, and C. 08-12-2020 13:34 documented, ?Note Text: Resident [#1] was agitated with exit seeking behaviors?? 4. Staff #1 confirmed resident #1 was in possession of a weapon despite the facility?s weapons policy that documented, ?For the safety of all, weapon are not allowed in the building? as documented in the resident agreement.
Plan of Correction:	Executive Director will be conducting a mandatory all staff meeting in regards to the community?s weapon policy. Moving forward, the Executive Director will review Weapons policy that is outlined in the Resident Agreement prior to move-in and again with any transfers to secure unit.