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: Feb. 23, 2022

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

Comments:

An unannounced renewal inspection was conducted by two Licensing Inspectors on 2/23/22 from 9:42am to 4:30pm. There were 71 residents in care at the time of the inspection. A tour of the facility was conducted and activities were observed. Medication passes were observed and staff and resident files were reviewed. 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 #:	22VAC40-73-350-B
Description:	Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. Resident #2 was admitted on 2/14/22 and the Sex Offender screening was completed on 2/23/22. 2. Resident #3 was admitted on 11/29/21 and the Sex Offender screening was completed on 2/23/22.
Plan of Correction:	Sex offender records will be obtained by the community prior to date of resident physical move-in. Business Office Manager or designee will confirm completion of record attainment prior to resident physical move-in.
Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition. Evidence: 1. Resident #1?s UAI was last completed on 10/26/20. 2. Resident #1 also had a significant change in condition as she was admitted to hospice on 1/1/22. 3. Resident #3 was admitted to the facility on 11/29/21 and the ISP was completed on 12/24/21.
Plan of Correction:	Resident #1 UAI/ ISP will be made current. Director of Clinical Services or designee will assure UAI initial assessment is completed prior to resident physical move-in. Executive Director or designee will confirm the UAI is completed prior to resident physical move-in. The Director of Clinical Services or designee will monitor UAI change of condition/annual review dates routinely to assure completion as scheduled. The UDA system will be utilized to maintain scheduling and compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview, the facility failed to review and update Individual Service Plans (ISP) at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #1?s ISP was last updated on 10/29/20. 2. Resident #1 is currently receiving hospice services which were not detailed on the ISP.
Plan of Correction:	Resident #1 ISP will be made current. Director of Clinical Services or designee will monitor ISP change of condition and annual review dates routinely to assure completion as needed/scheduled. The UDA system will be utilized to maintain scheduling and compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on observations made during the audit of the medication cart, the facility failed to adhere to methods to prevent the use of outdated, damaged, or contaminated medications. Evidence: During the medication cart audit the following outdated medications were observed: 1. Resident #4's Listerine had an expiration date of 8/25/21. 2. Resident #7?s Tiotropium Bromide 2.5 mcg inhaler had a Do Not Use after date of 1/25/22. 3. Resident #8?s Xelijanz Tabs had a "Use By" date of 09/08/2021. 4. Resident #8?s Montelukast Sod had a "Use By" date of 11/12/2020. 5. Resident #8?s Primidone 250mg had a "Use By" date of 8/18/2021. 6. Staff #1 acknowledged the medications were expired or outdated.
Plan of Correction:	A full medication cart audit will be completed to remove and address all expired medications. A monthly cart audit will be completed by the LPN charge nurse or designee to remove and address all expired medications during the month of the audit.
Standard #:	22VAC40-73-680-C
Description:	Based on observation, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. Staff #3 was observed administering medications at 10:18 am to Resident #5 and to Resident #3 at 10:30am. 2. Both medications were scheduled to be administered at 9:00am.
Plan of Correction:	A full medication cart audit will be completed to assure timeliness of medications is cohesive per resident and based on MD order. Staff in-services will be conducted based on policy and procedures related to the 5-rights of medication administration.